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BackgroundIncisional hernia (IH) is a known complication after colorectal surgery. Despite advances in minimally invasive surgery, colorectal surgery still requires extraction sites for specimen retrieval, increasing the likelihood of postoperative IH development. The objective of this study is to determine the effect of specimen extraction site on the rate of IH after minimally invasive right-sided colectomy for patients with available imaging.Study designThis is a retrospective multi-institutional cohort study at 2 large academic medical centers in the US. Adults who underwent right-sided minimally invasive colectomy from 2012 to 2020 with abdominal imaging available at least 1 year postoperatively were included in the analysis. The primary exposure was specimen extraction via a midline specimen extraction vs Pfannenstiel specimen extraction. The main outcome was the development of IH at least 1 year postoperatively as visualized on a CT scan.ResultsOf the 341 patients sampled, 194 (57%) had midline specimen extraction and 147 (43%) had a Pfannenstiel specimen extraction. Midline extraction patients were older (66 ± 15 vs 58 ± 16; p < 0.001) and had a higher rate of previous abdominal operation (99, 51% vs 55, 37%, p = 0.01). The rate of IH was higher in midline extraction at 25% (48) compared with Pfannenstiel extraction (0, 0%; p < 0.001). The average length of stay was higher in the midline extraction group at 5.1 ± 2.5 compared with 3.4 ± 3.1 days in the Pfannenstiel extraction group (p < 0.001). Midline extraction was associated with IH development (odds ratio 24.6; 95% CI 1.89 to 319.44; p = 0.004). Extracorporeal anastomosis was associated with a higher IH rate (odds ratio 25.8; 95% CI 2.10 to 325.71; p = 0.002).ConclusionsPatients who undergo Pfannenstiel specimen extraction have a lower risk of IH development compared with those who undergo midline specimen extraction.

IntroductionEarly initiation of chemotherapy after surgery for colon cancer has survival benefits. Immediate adjuvant chemotherapy (IAC) involves giving chemotherapy during surgical resection and immediately postoperatively. This novel approach has been shown to be safe, eliminating delays in adjuvant treatment that could increase the risk of micro-metastatic spread. The aim of this study was to assess the willingness of the general public to accept IAC.Materials and methodsBetween March and April 2021, 800 telephone interviews were conducted with a sample of adult New York State residents. The Survey Research Institute of Cornell University conducted all surveys. Kruskal-Wallis, chi-squared, and Fisher's tests were conducted using R 4.0.2.ResultsThree scenarios were presented: (1) receiving IAC resulting in improved survival and quality of life, (2) finishing chemotherapy earlier without survival impact, and (3) finishing chemotherapy earlier but with possible side effects. Respondents with higher education were more likely to accept (1) & (2), males were more likely to accept (2) & (3), higher income respondents were more likely to accept (1) & (3), and those with more work hours were more likely to accept (2). Lastly, 16% responded they would be very or extremely likely, and 52% respondents would be somewhat likely or likely to accept intraoperative chemotherapy, even if it may not be necessary.ConclusionsRespondents were likely to accept IAC if offered. Given the known risk of delayed adjuvant chemotherapy (AC) in colon cancer, further research is warranted to determine the survival and quality of life (QOL) benefits of IAC.

BackgroundIndocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials.ObjectiveWe hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection.DesignWe performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years.SettingsThis was a multicenter trial.PatientsIncluded patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge.InterventionPatients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy.Main outcome measuresPrimary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention.ResultsThis study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34).LimitationsThe predetermined sample size to adequately reduce the risk of type II error was not achieved.ConclusionsSuccessful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560.Valoracin de la irrigacin de lado izquierdo/reseccin anterior baja pilar iii un estudio aleatorizado, controlado, paralelo y multicntrico que evala los resultados de la irrigacin con pinpoint imgenes de fluorescencia cercana al infrarrojo en la reseccin anterior bajaANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.

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.

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.

BackgroundLaparoscopic 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.MethodsA 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.ResultsOf 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

Importance:Surgical and medical device manufacturers have a cooperative relationship with clinicians. When evaluating published works, one should assess the integrity and academic credentials of the authors, who serve as putative experts. A relationship with a relevant manufacturer may increase the potential risk for bias in relevant studies. Objective:To characterize the association of industrial payments by device manufacturers, self-declared conflict of interest (COI), and relevance of publications among physicians receiving the highest compensation. Design, Setting, and Participants:This population-based bibliometric analysis identified 10 surgical and medical device manufacturing companies and the 10 physicians receiving the highest compensation from each company using the 2015 Open Payments Database (OPD) general payments data. For each of the 100 physicians, the total amount of general payments, number of payments, institution type, and academic rank were recorded. Royalty or license payments were excluded. A search of PubMed identified articles published by each physician from January 1 through December 31, 2016, and their associated COI declaration. Scopus was used to identify bibliometric data reported as the h index (number of papers by a researcher with at least h citations each). Main Outcomes and Measures:Discrepancy between self-declared COI and industry payments. Results:The 100 physicians included in the sample population (88% men) were paid a total of $12 446 969, with a median payment of $95 993. Fifty physicians (50.0%) were faculty at academic institutions. The mean (SD) h index was 18 (18; range, 0-75) for the authors. In 2016, 412 articles were published by these physicians, with a mean (SD) of 4 (6) publications (range, 0-25) and median of 1 (36 physicians had no publications). Of these articles, 225 (54.6%) were relevant to the general payments received by the authors. Only in 84 of the 225 relevant publications (37.3%) was the potential COI declared by the authors. Conclusions and Relevance:A high level of inconsistency was found between self-declared COI and the OPD among the physicians receiving the highest industry payments. Therefore, a policy of full disclosure for all publications, regardless of relevance, is proposed. No statistically significant association was demonstrated between academic rank or productivity and industrial payments.

Importance:Surgical and medical device manufacturers have a cooperative relationship with clinicians. When evaluating published works, one should assess the integrity and academic credentials of the authors, who serve as putative experts. A relationship with a relevant manufacturer may increase the potential risk for bias in relevant studies. Objective:To characterize the association of industrial payments by device manufacturers, self-declared conflict of interest (COI), and relevance of publications among physicians receiving the highest compensation. Design, Setting, and Participants:This population-based bibliometric analysis identified 10 surgical and medical device manufacturing companies and the 10 physicians receiving the highest compensation from each company using the 2015 Open Payments Database (OPD) general payments data. For each of the 100 physicians, the total amount of general payments, number of payments, institution type, and academic rank were recorded. Royalty or license payments were excluded. A search of PubMed identified articles published by each physician from January 1 through December 31, 2016, and their associated COI declaration. Scopus was used to identify bibliometric data reported as the h index (number of papers by a researcher with at least h citations each). Main Outcomes and Measures:Discrepancy between self-declared COI and industry payments. Results:The 100 physicians included in the sample population (88% men) were paid a total of $12 446 969, with a median payment of $95 993. Fifty physicians (50.0%) were faculty at academic institutions. The mean (SD) h index was 18 (18; range, 0-75) for the authors. In 2016, 412 articles were published by these physicians, with a mean (SD) of 4 (6) publications (range, 0-25) and median of 1 (36 physicians had no publications). Of these articles, 225 (54.6%) were relevant to the general payments received by the authors. Only in 84 of the 225 relevant publications (37.3%) was the potential COI declared by the authors. Conclusions and Relevance:A high level of inconsistency was found between self-declared COI and the OPD among the physicians receiving the highest industry payments. Therefore, a policy of full disclosure for all publications, regardless of relevance, is proposed. No statistically significant association was demonstrated between academic rank or productivity and industrial payments.

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

BackgroundAnastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak.MethodsFrom 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving 30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line.ResultsFrom 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023).ConclusionEndoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

BackgroundAnastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak.MethodsFrom 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving 30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line.ResultsFrom 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023).ConclusionEndoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

BackgroundPatients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1

BackgroundPatients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1

BackgroundThe effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery.Study designA total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge.ResultsMean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m2. The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure ( 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges ($144,991 ± $67,636 vs $141,339 ± $75,579; p > 0.05).ConclusionsThis study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

ObjectiveNational examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).BackgroundSurgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.MethodsRetrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS.ResultsOf 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).ConclusionIn the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

ObjectiveNational examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).BackgroundSurgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.MethodsRetrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS.ResultsOf 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).ConclusionIn the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Adhesions account for 74 per cent of admissions for small bowel obstruction (SBO). There is a lack of data regarding the usage and outcomes of laparoscopy (LS) for SBO. A retrospective review of urgent admissions for SBO using the Nationwide Inpatient Sample 2001 to 2011 was conducted. Among the estimated 3,948,987 SBO admissions, 36.7 per cent underwent operative management and LS was performed in 26.5 per cent with a 22.5 per cent conversion rate. Admissions increased by 3.1 per cent annually, whereas nonoperative management increased by 3.8 per cent annually. Operative management increased by 1.8 per cent annually, whereas LS increased by 8.9 per cent annually and open surgery decreased by 0.6 per cent annually. LS small bowel resection increased by a mean of 25 per cent annually. LS was associated with a 24.4 per cent in-hospital morbidity with intra-abdominal abscess/enteric fistulas (8.3%) and ileus (8.9%) as the most common complications. In-hospital mortality was 0.9 per cent with length of stay of 13 ± 9 days and a hospital charge of $80,080 ± 6,634. The majority of patients were operated on hospital day (HD) 1 (43.0%). Patients who underwent LS on HD >7 had a higher risk-adjusted mortality compared with earlier HD (odds ratio = 2.63; 95% confidence interval: 2.40-2.89; P < 0.01). There has been an increase in admissions for SBO and an increase in LS over the past 11 years. There seems to be an increase in mortality and morbidity with a later HD operation.

Adhesions account for 74 per cent of admissions for small bowel obstruction (SBO). There is a lack of data regarding the usage and outcomes of laparoscopy (LS) for SBO. A retrospective review of urgent admissions for SBO using the Nationwide Inpatient Sample 2001 to 2011 was conducted. Among the estimated 3,948,987 SBO admissions, 36.7 per cent underwent operative management and LS was performed in 26.5 per cent with a 22.5 per cent conversion rate. Admissions increased by 3.1 per cent annually, whereas nonoperative management increased by 3.8 per cent annually. Operative management increased by 1.8 per cent annually, whereas LS increased by 8.9 per cent annually and open surgery decreased by 0.6 per cent annually. LS small bowel resection increased by a mean of 25 per cent annually. LS was associated with a 24.4 per cent in-hospital morbidity with intra-abdominal abscess/enteric fistulas (8.3%) and ileus (8.9%) as the most common complications. In-hospital mortality was 0.9 per cent with length of stay of 13 ± 9 days and a hospital charge of $80,080 ± 6,634. The majority of patients were operated on hospital day (HD) 1 (43.0%). Patients who underwent LS on HD >7 had a higher risk-adjusted mortality compared with earlier HD (odds ratio = 2.63; 95% confidence interval: 2.40-2.89; P < 0.01). There has been an increase in admissions for SBO and an increase in LS over the past 11 years. There seems to be an increase in mortality and morbidity with a later HD operation.

BackgroundPatients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.DesignA retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality.ResultsAmong 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19-1.03), p = 0.18; OR 1.55 CI (0.86-2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001).ConclusionLaparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

BackgroundPatients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.DesignA retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality.ResultsAmong 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19-1.03), p = 0.18; OR 1.55 CI (0.86-2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001).ConclusionLaparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

BackgroundOur primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion.Study designThis is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States.ResultsA total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA.ConclusionsPINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

BackgroundOur primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion.Study designThis is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States.ResultsA total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA.ConclusionsPINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

BackgroundIn 2006, the Centers for Medicare and Medicaid Services issued a National Coverage Determination (NCD), which mandates that bariatric procedures be performed only at accredited centers. The aim of this study was to analyze outcomes of Medicare beneficiaries who underwent bariatric surgery before (2001 through 2005) vs after (2006 through 2010) implementation of the NCD.Study designThe Nationwide Inpatient Sample database was used to analyze data on patients who underwent bariatric surgery between 2001 and 2010. Main outcomes measures were demographics, length of stay, risk-adjusted inpatient morbidity and mortality, and cost.ResultsThere were 775,040 patients who underwent bariatric surgery, with 16% of the patients Medicare beneficiaries. There was an overall trend for improved in-hospital mortality during the decade (0.35% in 2001 to 0.10% in 2010). Medicare patients who underwent bariatric surgery had higher rates of comorbidities and a higher rate of in-hospital mortality than non-Medicare patients. After the NCD, there was a significant reduction of the in-hospital mortality (0.56% vs 0.23%; p < 0.01) and serious morbidity (9.92% vs 6.98%; p < 0.01) for Medicare patients and a similar reduction of the in-hospital mortality (0.18% vs 0.08%; p < 0.01) and serious morbidity (6.84% vs 5.08%; p < 0.01) for non-Medicare patients. Compared with patients who underwent stapling bariatric procedures at accredited centers, patients at nonaccredited centers had higher risk-adjusted in-hospital mortality (odds ratio = 3.53; 95% CI, 1.01-6.52) and serious morbidity (odds ratio = 1.18; 95% CI, 1.07-1.30). After the NCD, use of bariatric surgery within Medicare beneficiaries increased by 71%.ConclusionsOutcomes of bariatric surgery in Medicare beneficiaries have improved substantially since the 2006 NCD. Facility accreditation appears to be a contributing factor to the observed improvement in outcomes.

ImportanceThe incidence of colorectal cancer in elderly patients is likely to increase, but there is a lack of large nationwide data regarding the mortality and morbidity of colorectal cancer resections in the aging population.ObjectiveTo examine the surgical trends and outcomes of colorectal cancer treatment in the elderly.Design, setting, and participantsA review of operative outcomes for colorectal cancer in the United States was conducted in a Nationwide Inpatient Sample from January 1, 2001, through December 31, 2010. Patients were stratified within age groups of 45 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and 85 years and older. Postoperative complications and yearly trends were analyzed. A multivariate logistic regression was used to compare in-hospital mortality and morbidity between individual groups of patients 65 years and older and those aged 45 to 64 years while controlling for sex, comorbidities, procedure type, diagnosis, and hospital status.Main outcomes and measuresIn-hospital mortality and morbidity.ResultsAmong the estimated 1,043,108 patients with colorectal cancer sampled, 63.8% of the operations were performed on those 65 years and older and 22.6% on patients 80 years and older. Patients 80 years and older were 1.7 times more likely to undergo urgent admission than those younger than 65 years. Patients younger than 65 years accounted for 46.0% of the laparoscopies performed in the elective setting compared with 14.1% for patients 80 years and older. Mortality during the 10 years decreased by a mean of 6.6%, with the most considerable decrease observed in the population 85 years and older (9.1%). Patients 80 years and older had an associated $9492 higher hospital charge and an increased 2½-day length of stay vs patients younger than 65 years. Compared with patients aged 45 to 64 years, higher risk-adjusted in-hospital mortality was observed in patients with advancing age: 65 to 69 years (odds ratio, 1.32; 95% CI, 1.18-1.49), 70 to 74 years (2.02; 1.82-2.24), 75 to 79 years (2.51; 2.28-2.76), 80 to 84 years (3.15; 2.86-3.46), and 85 years and older (4.72; 4.30-5.18) (P

ImportanceThe incidence of colorectal cancer in elderly patients is likely to increase, but there is a lack of large nationwide data regarding the mortality and morbidity of colorectal cancer resections in the aging population.ObjectiveTo examine the surgical trends and outcomes of colorectal cancer treatment in the elderly.Design, setting, and participantsA review of operative outcomes for colorectal cancer in the United States was conducted in a Nationwide Inpatient Sample from January 1, 2001, through December 31, 2010. Patients were stratified within age groups of 45 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and 85 years and older. Postoperative complications and yearly trends were analyzed. A multivariate logistic regression was used to compare in-hospital mortality and morbidity between individual groups of patients 65 years and older and those aged 45 to 64 years while controlling for sex, comorbidities, procedure type, diagnosis, and hospital status.Main outcomes and measuresIn-hospital mortality and morbidity.ResultsAmong the estimated 1,043,108 patients with colorectal cancer sampled, 63.8% of the operations were performed on those 65 years and older and 22.6% on patients 80 years and older. Patients 80 years and older were 1.7 times more likely to undergo urgent admission than those younger than 65 years. Patients younger than 65 years accounted for 46.0% of the laparoscopies performed in the elective setting compared with 14.1% for patients 80 years and older. Mortality during the 10 years decreased by a mean of 6.6%, with the most considerable decrease observed in the population 85 years and older (9.1%). Patients 80 years and older had an associated $9492 higher hospital charge and an increased 2½-day length of stay vs patients younger than 65 years. Compared with patients aged 45 to 64 years, higher risk-adjusted in-hospital mortality was observed in patients with advancing age: 65 to 69 years (odds ratio, 1.32; 95% CI, 1.18-1.49), 70 to 74 years (2.02; 1.82-2.24), 75 to 79 years (2.51; 2.28-2.76), 80 to 84 years (3.15; 2.86-3.46), and 85 years and older (4.72; 4.30-5.18) (P

ImportanceHyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC.ObjectiveTo determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers.Design, setting, and participantsA retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011.Main outcomes and measuresThirty-day mortality and morbidity.ResultsOf the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%.Conclusions and relevanceAmerican College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of morbidity and mortality.

BACKGROUND: Iatrogenic ureteral injuries during colorectal surgical procedures are rare. Little is known about their incidence, associated outcomes, and predisposing factors. OBJECTIVE: The purpose of this study was to examine the trends of iatrogenic ureteral injuries in the United States over a decade, as well as their outcomes and risk factors. DESIGN: This was a retrospective study. SETTINGS: The nationwide inpatient sample from 2001 to 2010 was analyzed. PATIENTS: Included were patients with colorectal cancer, benign polyps, diverticular disease, or inflammatory bowel disease undergoing colorectal surgery. MAIN OUTCOME MEASURES: Trends of iatrogenic ureteral injuries occurring in colon and rectal surgical procedures were examined over a 10-year period. Mortality, morbidity, length of stay and total charge associated with ureteral injuries were analyzed on multivariate analysis. Finally, a predictive model for ureteral injuries was built using patient, hospital, and operative variables. RESULTS: An estimated 2,165,848 colorectal surgical procedures were performed in the United States over the study period, and 6027 ureteral injuries were identified (0.28%). The rate of ureteral injuries was higher in the second half of the decade (2006-2010) compared with the first half (2001-2005; 3.1/1000 vs 2.5/1000; p < 0.001). Ureteral injuries were independently associated with higher mortality (OR, 1.45; p < 0.05), morbidity (OR, 1.66; p < 0.001), longer length of stay (mean difference, 3.65 days; p < 0.001), and higher hospital charges by $31,497 (p< 0.001). Risk factors for ureteral injuries included rectal cancer (OR, 1.85), adhesions (OR, 1.83), metastatic cancer (OR, 1.76), weight loss/malnutrition (OR, 1.08), and teaching hospitals (OR, 1.05). Protective factors included the use of laparoscopy (OR, 0.91), transverse colectomy (OR, 0.90), and right colectomy (OR, 0.43). LIMITATIONS: This was a retrospective study from an administrative database. CONCLUSIONS: Iatrogenic ureteral injuries are rare complications in colorectal surgery; however, their incidence appears to be rising. Ureteral injuries are associated with higher mortality, morbidity, hospital charge, and length of stay, and their incidence can be predicted by several factors.

IntroductionColonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level.MethodsThe Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables.ResultsAn estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality.ConclusionsColonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

IntroductionColonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level.MethodsThe Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables.ResultsAn estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality.ConclusionsColonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

BACKGROUND: Iatrogenic ureteral injuries during colorectal surgical procedures are rare. Little is known about their incidence, associated outcomes, and predisposing factors. OBJECTIVE: The purpose of this study was to examine the trends of iatrogenic ureteral injuries in the United States over a decade, as well as their outcomes and risk factors. DESIGN: This was a retrospective study. SETTINGS: The nationwide inpatient sample from 2001 to 2010 was analyzed. PATIENTS: Included were patients with colorectal cancer, benign polyps, diverticular disease, or inflammatory bowel disease undergoing colorectal surgery. MAIN OUTCOME MEASURES: Trends of iatrogenic ureteral injuries occurring in colon and rectal surgical procedures were examined over a 10-year period. Mortality, morbidity, length of stay and total charge associated with ureteral injuries were analyzed on multivariate analysis. Finally, a predictive model for ureteral injuries was built using patient, hospital, and operative variables. RESULTS: An estimated 2,165,848 colorectal surgical procedures were performed in the United States over the study period, and 6027 ureteral injuries were identified (0.28%). The rate of ureteral injuries was higher in the second half of the decade (2006-2010) compared with the first half (2001-2005; 3.1/1000 vs 2.5/1000; p < 0.001). Ureteral injuries were independently associated with higher mortality (OR, 1.45; p < 0.05), morbidity (OR, 1.66; p < 0.001), longer length of stay (mean difference, 3.65 days; p < 0.001), and higher hospital charges by $31,497 (p< 0.001). Risk factors for ureteral injuries included rectal cancer (OR, 1.85), adhesions (OR, 1.83), metastatic cancer (OR, 1.76), weight loss/malnutrition (OR, 1.08), and teaching hospitals (OR, 1.05). Protective factors included the use of laparoscopy (OR, 0.91), transverse colectomy (OR, 0.90), and right colectomy (OR, 0.43). LIMITATIONS: This was a retrospective study from an administrative database. CONCLUSIONS: Iatrogenic ureteral injuries are rare complications in colorectal surgery; however, their incidence appears to be rising. Ureteral injuries are associated with higher mortality, morbidity, hospital charge, and length of stay, and their incidence can be predicted by several factors.

ImportanceHyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC.ObjectiveTo determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers.Design, setting, and participantsA retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011.Main outcomes and measuresThirty-day mortality and morbidity.ResultsOf the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%.Conclusions and relevanceAmerican College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of morbidity and mortality.

BackgroundData analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables.ResultsA total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was "dose dependent," as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit

BackgroundWhile robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level.MethodsThe Nationwide Inpatient Sample 2009-2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS).ResultsAn estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82-16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79-19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27- 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25-0.67) and (0.10; 95 % CI 0.06-0.16), respectively.ConclusionsThe use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.

BackgroundThe relationship between volume and outcomes in bariatric surgery is well established in the literature. However, the analyses were performed primarily in the open surgery era and in the absence of national accreditation. The recent Metabolic Bariatric Surgery Accreditation and Quality Improvement Program proposed an annual threshold volume of 50 stapling cases. This study aimed to examine the effect of volume and accreditation on surgical outcomes for bariatric surgery in this laparoscopic era.MethodsThe Nationwide Inpatient Sample was used for analysis of the outcomes experienced by morbidly obese patients who underwent an elective laparoscopic stapling bariatric surgical procedure between 2006 and 2010. In this analysis, low-volume centers (LVC < 50 stapling cases/year) were compared with high-volume centers (HVC ≥ 50 stapling cases/year). Multivariate analysis was performed to examine risk-adjusted serious morbidity and in-hospital mortality between the LVCs and HVCs. Additionally, within the HVC group, risk-adjusted outcomes of accredited versus nonaccredited centers were examined.ResultsBetween 2006 and 2010, 277,760 laparoscopic stapling bariatric procedures were performed, with 85% of the cases managed at HVCs. The mean number of laparoscopic stapling cases managed per year was 17 ± 14 at LVCs and 144 ± 117 at HVCs. The in-hospital mortality was higher at LVCs (0.17%) than at HVCs (0.07%). Multivariate analysis showed that laparoscopic stapling procedures performed at LVCs had higher rates of mortality than those performed at HVCs [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.3-4.8; p < 0.01] as well as higher rates of serious morbidity (OR 1.2; 95% CI 1.1-1.4; p < 0.01). The in-hospital mortality rate at nonaccredited HVCs was 0.22% compared with 0.06% at accredited HVCs. Multivariate analysis showed that nonaccredited centers had higher rates of mortality than accredited centers (OR 3.6; 95% CI 1.5-8.3; p < 0.01) but lower rates of serious morbidity (OR 0.8; 95% CI 0.7-0.9; p < 0.01).ConclusionIn this era of laparoscopy, hospitals managing more than 50 laparoscopic stapling cases per year have improved outcomes. However, nonaccredited HVCs have outcomes similar to those of LVCs. Therefore, the impact of accreditation on outcomes may be greater than that of volume.

BackgroundData analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables.ResultsA total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was "dose dependent," as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit

BackgroundParastomal hernia (PSH) is a frequent complication following the creation of a stoma. While a significant number of cases require operative management, data comparing short-term outcomes of laparoscopic versus open repair of parastomal hernias are limited.MethodsThe ACS-NSQIP was retrospectively reviewed from 2005 to 2011 for all PSH cases that underwent open or laparoscopic repair. Patients characteristics, operative details, and outcomes were listed for both procedure types. Selected end points were compared on multivariate regression analysis.ResultsAmong the 2,167 identified parastomal hernia cases, only 222 (10.24 %) were treated laparoscopically. The open and laparoscopic groups were similar with respect to mean patient age (63 vs. 63 years; p = 1) and gender distribution as the majority of patients were females (56.8 %). However, open repair was more likely to be performed in patients with a higher ASA class (III and IV) (p < 0.001). Also, the open approach was more likely to be used emergently (8.64 vs. 3.60 %; p = 0.01) and for recurrent hernias (6.99 vs. 3.15 %; p < 0.05). After adjusting for all potential confounders including age, gender, ASA, emergency designation of the operation, hernia type, and wound class, laparoscopy was associated with shorter operative time (137.5 vs. 153.4 min; p < 0.05), shorter length of hospital stay by 3.32 days (p < 0.001), lower risk of overall morbidity (OR = 0.42; p < 0.001), and a lower risk of surgical site infections (OR = 0.35; p < 0.01) compared to open repair. Mortality rates were similar in the laparoscopic and open groups (0.45 vs. 1.59 %, respectively; p = 0.29).ConclusionsLaparoscopic parastomal hernia repair is safe and appears to be associated with better short-term outcomes compared to open repair in selected cases. Large prospective randomized trials are needed to confirm those results and to assess long-term recurrence rates.

There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.

There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.

There is paucity of data evaluating the trends and outcomes of colorectal surgery (CRS) in kidney transplant recipients (KTRs). Using the Nationwide Inpatient Sample 2001 to 2010, a retrospective review of CRS performed in KTRs was performed. Trends, demographics, indications, and outcomes were examined for elective and emergent cases and compared with the general population (GP) on multivariate logistic regression. A total of 2616 KTRs underwent CRS, 50 per cent of which were done emergently. KTRs developed colon and rectal cancer at a younger age and had significantly higher incidence of comorbidities compared with the GP. Diverticular disease was the most common indication for surgery (48%) followed by cancer (30.6%). Compared with the GP, KTRs had higher rates of mortality (6.29 vs 3.64%), wound complications (8.02 vs 5.37%), and acute renal failure (ARF) (17.14 vs 7.10%) (all P < 0.05). No difference was seen in the incidence of anastomotic leak. On multivariate analysis, KTRs had higher associated odds of ARF (odds ratio, 2.02; P < 0.001), whereas the odds of mortality, wound, and anastomotic complications were similar to the GP. Emergency surgery in KTRs was associated with worse outcomes compared with the elective setting. KTRs undergoing CRS have unique characteristics that are different than the GP. They are at an increased risk of complications, especially acute renal failure.

There is paucity of data evaluating the trends and outcomes of colorectal surgery (CRS) in kidney transplant recipients (KTRs). Using the Nationwide Inpatient Sample 2001 to 2010, a retrospective review of CRS performed in KTRs was performed. Trends, demographics, indications, and outcomes were examined for elective and emergent cases and compared with the general population (GP) on multivariate logistic regression. A total of 2616 KTRs underwent CRS, 50 per cent of which were done emergently. KTRs developed colon and rectal cancer at a younger age and had significantly higher incidence of comorbidities compared with the GP. Diverticular disease was the most common indication for surgery (48%) followed by cancer (30.6%). Compared with the GP, KTRs had higher rates of mortality (6.29 vs 3.64%), wound complications (8.02 vs 5.37%), and acute renal failure (ARF) (17.14 vs 7.10%) (all P < 0.05). No difference was seen in the incidence of anastomotic leak. On multivariate analysis, KTRs had higher associated odds of ARF (odds ratio, 2.02; P < 0.001), whereas the odds of mortality, wound, and anastomotic complications were similar to the GP. Emergency surgery in KTRs was associated with worse outcomes compared with the elective setting. KTRs undergoing CRS have unique characteristics that are different than the GP. They are at an increased risk of complications, especially acute renal failure.

ObjectiveTo examine the trends and outcomes of partial esophagectomy with an intrathoracic anastomosis compared with total esophagectomy with a cervical anastomosis.BackgroundControversy exists regarding the optimal surgical approach in the management of esophageal cancer.MethodsUsing the Nationwide Inpatient Sample database, yearly trends of patients with esophageal cancer who underwent partial and total esophagectomy were analyzed. Multivariate logistic regression analysis was used to analyze serious morbidity and in-hospital mortality between partial and total esophagectomy. In addition, outcomes were analyzed according to hospital volume, with low-volume centers defined as those with fewer than 10 cases per year and high-volume centers as those with 10 or more cases per year.ResultsBetween 2001 and 2010, 15,190 esophagectomies were performed for cancer. There was an overall increase in the number of esophagectomy procedures performed (1402 to 1975), with a concomitant reduction in the mortality rate (8.3% to 4.2%), particularly for partial esophagectomy. Partial esophagectomy was the predominant operation (76%). Most operations were performed at low-volume centers (62%), with a recent shift of cases to high-volume center. Compared with total esophagectomy, partial esophagectomy was associated with a shorter length of hospital stay (16 ± 6 vs 19 ± 9 days; P < 0.05), a lower in-hospital mortality rate (5.8% vs 8.3%; P < 0.05), and a lower hospital charge ($119,339 vs $138,496; P < 0.05). On multivariate regression analysis, total esophagectomy was associated with higher serious morbidity (odds ratio, 1.39; P < 0.01) and in-hospital mortality (odds ratio, 1.67; P = 0.03). There were no significant differences in risk-adjusted outcomes between low-volume centers and high-volume center.ConclusionsThe number of esophagectomies performed for esophageal cancer has increased over the past decade accompanied by an overall reduction in mortality, particularly for the partial esophagectomy approach. The predominant operation in the United States continues to be partial esophagectomy with an intrathoracic anastomosis, which was associated with lower morbidity and in-hospital mortality than total esophagectomy. Hospital volume at a threshold of 10 cases per year was not a predictor of outcome.

ObjectiveTo examine the trends and outcomes of partial esophagectomy with an intrathoracic anastomosis compared with total esophagectomy with a cervical anastomosis.BackgroundControversy exists regarding the optimal surgical approach in the management of esophageal cancer.MethodsUsing the Nationwide Inpatient Sample database, yearly trends of patients with esophageal cancer who underwent partial and total esophagectomy were analyzed. Multivariate logistic regression analysis was used to analyze serious morbidity and in-hospital mortality between partial and total esophagectomy. In addition, outcomes were analyzed according to hospital volume, with low-volume centers defined as those with fewer than 10 cases per year and high-volume centers as those with 10 or more cases per year.ResultsBetween 2001 and 2010, 15,190 esophagectomies were performed for cancer. There was an overall increase in the number of esophagectomy procedures performed (1402 to 1975), with a concomitant reduction in the mortality rate (8.3% to 4.2%), particularly for partial esophagectomy. Partial esophagectomy was the predominant operation (76%). Most operations were performed at low-volume centers (62%), with a recent shift of cases to high-volume center. Compared with total esophagectomy, partial esophagectomy was associated with a shorter length of hospital stay (16 ± 6 vs 19 ± 9 days; P < 0.05), a lower in-hospital mortality rate (5.8% vs 8.3%; P < 0.05), and a lower hospital charge ($119,339 vs $138,496; P < 0.05). On multivariate regression analysis, total esophagectomy was associated with higher serious morbidity (odds ratio, 1.39; P < 0.01) and in-hospital mortality (odds ratio, 1.67; P = 0.03). There were no significant differences in risk-adjusted outcomes between low-volume centers and high-volume center.ConclusionsThe number of esophagectomies performed for esophageal cancer has increased over the past decade accompanied by an overall reduction in mortality, particularly for the partial esophagectomy approach. The predominant operation in the United States continues to be partial esophagectomy with an intrathoracic anastomosis, which was associated with lower morbidity and in-hospital mortality than total esophagectomy. Hospital volume at a threshold of 10 cases per year was not a predictor of outcome.

BackgroundDecreased blood perfusion at an intestinal anastomosis may contribute to postoperative anastomotic leak (AL) resulting in substantial morbidity and mortality. Near-infrared (NIR) laparoscopy in conjunction with indocyanine green (ICG) allows for visualization of the microcirculation before formation of the anastomosis, thereby allowing the surgeon to choose the point of transection at an optimally perfused area.MethodsThis is a retrospective case-control analysis examining the effectiveness of NIR + ICG in reducing the rate of AL after low anterior resection (LAR) for rectal cancer. Records of patients undergoing robot-assisted LAR for rectal cancer with and without ICG were analyzed for the years 2011 and 2012.ResultsAmong the 40 patients who underwent robotic LAR, NIR + ICG was used in 16 cases (41 %). Male patients accounted for the majority of cases in both groups (74 %). The median level of the anastomosis was 3.5 cm in the NIR + ICG group and 5.5 cm in the control group. There was no difference in the use of diverting ileostomy. In 3 patients (19 %), the use of NIR + ICG resulted in revision of the proximal bowel (colonic) transection point before formation of the anastomosis. The distal transection point was never revised. The rate of AL in the NIR + ICG group was 6 % versus 18 % in control group.ConclusionsICG fluorescence may play a role in anastomotic tissue perfusion assessment and affect the AL rate. Larger prospective studies are needed to further validate this novel technology.

BackgroundLaparoscopic surgery has become increasing popular, and its use has been proven safe. However, major vascular injuries during laparoscopic procedures can have devastating effects, and there is a paucity of information regarding their intraoperative management. Here we report our experience with laparoscopic vascular injury repair and analyze the available literature on this topic.MethodsTwo cases of iliac vessel injury during laparoscopic colectomy were reviewed from a single surgeon's experience with of over 1,000 major laparoscopic procedures. The details of injury, techniques used, and outcomes were analyzed. A review of the literature was also conducted via PubMed.ResultsAn injury to the left common iliac artery in a 75-year-old man and an injury to the left external iliac vein in a 39-year-old man during laparoscopic sigmoid colectomy are described, with successful laparoscopic vascular repair in both. Estimated blood loss was 300 and 250 ml, respectively. Patients were discharged home on postoperative days 4 and 3 without complications. A review of the literature yielded descriptions of a total of 704 major vascular injuries, with 6 case reports of vascular injuries involving the iliac vessels and inferior vena cava with successful laparoscopic repair.ConclusionsLaparoscopic repair of major vasculature is feasible if sound techniques are followed. We describe a stepwise technique for dealing with intraoperative laparoscopic vascular injury.

IntroductionEpidural analgesia has demonstrated superiority over conventional analgesia in controlling pain following open colorectal resections. Controversy exists regarding cost-effectiveness and postoperative outcomes.MethodsThe Nationwide Inpatient Sample (2002-2010) was retrospectively reviewed for elective open colorectal surgeries performed for benign and malignant conditions with or without the use of epidural analgesia. Multivariate regression analysis was used to compare outcomes between epidural and conventional analgesia.ResultsA total 888,135 patients underwent open colorectal resections. Epidural analgesia was only used in 39,345 (4.4 %) cases. Epidurals were more likely to be used in teaching hospitals and rectal cancer cases. On multivariate analysis, in colonic cases, epidural analgesia lowered hospital charges by US$4,450 (p