Publisher Correction: Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties
Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties
BACKGROUND:Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches. STUDY DESIGN/METHODS:Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure. RESULTS:A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77Â day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS. CONCLUSION/CONCLUSIONS:At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.
Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality
BACKGROUND:Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patientsâ€‰â‰¥â€‰65Â years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reachâ€‰â‰¤â€‰0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians. METHODS:We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with ageâ€‰â‰¥â€‰65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR. RESULTS:Patients ageâ€‰â‰¥â€‰65 had a higher 30-day mortality (0.5% vs 0.2%; pâ€‰<â€‰0.001). Subset analysis of patients age 65-80 andâ€‰>â€‰80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (pâ€‰<â€‰0.001). Independent predictors of mortality in patientsâ€‰â‰¥â€‰65Â years were ageâ€‰>â€‰80 (OR 5.23, pâ€‰<â€‰0.001) and COPD (OR 2.59, pâ€‰=â€‰0.04). Patientsâ€‰â‰¥â€‰65 had a slightly higher incidence of pneumonia (2% vs 1.2%; pâ€‰<â€‰0.001), unplanned intubation (0.8% vs 0.5%; pâ€‰<â€‰0.05), pulmonary embolism (0.7% vs 0.3%; pâ€‰=â€‰0.001), bleeding requiring transfusion (1% vs 0.5%; pâ€‰<â€‰0.05), and LOS (2.38 vs 1.86Â days, pâ€‰<â€‰0.001) with no difference in sepsis, return to OR or readmission. CONCLUSION/CONCLUSIONS:This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patientsâ€‰<â€‰80Â years toward elective repair of PEH.
International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative
OBJECTIVE:The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND:The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS:Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS:One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS:The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.
Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center
Fascial closure at 8-mm robotic port sites continues to be controversial. As the use of the robotic platform increases across multiple abdominal specialties, there are more case reports describing reoperation and small bowel resection for acute port-site hernias. A retrospective review of all robotic abdominal surgeries performed from 2012 to 2019 at NYU Langone Medical Center was conducted. Patients who had a reoperation in our facility within 30Â days were identified, and medical records reviewed for indications for reoperation and findings. The study included 11,566 patients, of which 82 patients (0.71%) underwent a reoperation related to the index robotic surgery within 30Â days. Fifteen of 11,566 patients (0.13%) had acute port-site hernias, and 3 of these 15 patients required small bowel resection. Eleven of 15 acute port-site hernias (73%) were at 8-mm robotic port site, 2 of which required a small bowel resection. More than a third of the patients had a hernia at an 8-mm port site where a surgical drain had been placed. Considering that each robotic case, regardless of specialty, has three ports at a minimum, the true incidence of acute postoperative robotic port-site hernia is 0.032% (11/34,698), with the incidence of concomitant small bowel resection being 0.006% (2/34,698). The incidence of acute port-site hernias from 8-mm robotic ports is exceedingly low across specialties. Our results do not support routine fascial closure at 8-mm robotic port sites due to an extremely low incidence. However, drain sites require special consideration.
Hyperlipasemia in absence of acute pancreatitis is associated with elevated D-dimer and adverse outcomes in COVID 19 disease
BACKGROUND:Coronavirus SARS-CoV-2 affects multiple organs. Studies have reported mild elevations of lipase levels of unclear significance. Our study aims to determine the outcomes in patients with COVID-19 and hyperlipasemia, and whether correlation with D-dimer levels explains the effect on outcomes. METHODS:Case-control study from two large tertiary care health systems, of patients with COVID-19 disease admitted between March 1 and May 1, 2020 who had lipase levels recorded. Data analyzed to study primary outcomes of mortality, length of stay (LOS) and intensive care utilization in hyperlipasemia patients, and correlation with D-dimer and outcomes. RESULTS:992 out of 5597 COVID-19 patients had lipase levels, of which 429 (43%) had hyperlipasemia. 152 (15%) patients had a lipaseÂ >Â 3x ULN, with clinical pancreatitis in 2 patients. Hyperlipasemia had a higher mortality than normal lipase patients (32% vs. 23%, ORÂ =Â 1.6,95%CIÂ =Â 1.2-2.1, PÂ =Â 0.002). In subgroup analysis, hyperlipasemia patients had significantly worse LOS (11vs.15 days, PÂ =Â 0.01), ICU admission rates (44% vs. 66%,ORÂ =Â 2.5,95%CIÂ =Â 1.3-5.0,PÂ =Â 0.008), ICU LOS (12vs.19 days,PÂ =Â 0.01), mechanical ventilation rates (34% vs. 55%,ORÂ =Â 2.4,95%CIÂ =Â 1.3-4.8,PÂ =Â 0.01), and durations of mechanical ventilation (14 vs. 21 days, PÂ =Â 0.008). Hyperlipasemia patients were more likely to have a D-dimer value in the highest two quartiles, and had increased mortality (59% vs. 15%,ORÂ =Â 7.2,95%CIÂ =Â 4.5-11,PÂ <Â 0.001) and LOS (10vs.7 days,PÂ <Â 0.001) compared to those with normal lipase and lower D-dimer levels. CONCLUSION/CONCLUSIONS:There is high prevalence of hyperlipasemia without clinical pancreatitis in COVID-19 disease. Hyperlipasemia was associated with higher mortality and ICU utilization, possibly explained by elevated D-dimer.
Narrative review of laparoscopic management of hepatic cysts
Hepatic cysts are a common and often asymptomatic finding. In this review we will discuss the diagnosis and treatment of hepatic cysts with a specific focus on minimally invasive surgical approaches. Most simple cysts are asymptomatic and do not require intervention. As cysts increase in size they may cause a range of symptoms including satiety, fullness, a palpable mass, and rarely bleeding or secondary infection. Surgical approaches are reserved for symptomatic lesions, and hydatid disease. It is important to rule out bacterial infection (abscess) and neoplasm in the work up of hepatic cysts. While cysts are often detected by ultrasound, Computed tomography and Magnetic Resonance Imaging are the primary modes of assessment for these lesions. Most cysts can be managed by unroofing or marsupialization alone, with formal liver resection rarely required. Minimally invasive surgery (MIS) techniques have been described for many years including laparoscopic and recently, robotic approaches. Hydatid cysts require special attention to control of contents to avoid anaphylaxis but can also be managed laparoscopically. Laparoscopic and/or robotic surgery can be performed safely and is effective in the treatment of cystic disease of the liver. Mortality should be below 1%, and overall morbidity less than 10%. Recurrence rates for simple cysts are generally below 10%, however polycystic liver disease (PLD) does have a higher recurrence rate after marsupialization than simple cysts.
Extensive Gastric Necrosis in the Setting of Phytobezoar Causing Gastric Outlet Obstruction
Practical Implications of Novel Coronavirus COVID-19 on Hospital Operations, Board Certification, and Medical Education in Surgery in the USA
THE EFFICACY, SAFETY, AND LONG-TERM DURABILITY OF LUMEN-APPOSING METAL STENTS IN THE MANAGEMENT OF BENIGN LUMINAL STRICTURES [Meeting Abstract]
Background: Lumen-apposing self-expandable metal stents (LAMS) have transformed the management of pancreatic fluid collections over the last two decades. There has since been significant interest in expanding the utility of LAMS for additional therapies such as the management of benign luminal strictures. However, there remains little data on their efficacy and safety when used for this indication. The goal of this study was to define the technical success, clinical success, and complication rates of LAMS when used in the management of benign strictures Methods: This was a retrospective multicenter evaluation of the safety, efficacy, and long-term clinical durability of LAMS in the treatment of benign strictures. The study took place between June 2018 and November 2019. Data collection included demographic information, indication, stent size, use of concurrent balloon dilation including dilation diameter, stent stabilization technique, intra-procedure and post-procedure complications, clinical improvement, and post-procedure follow up outcomes.
Result(s): 30 patients underwent placement of LAMS for a benign luminal stricture, with one having two stents placed during the index procedure at separate areas of stenoses resulting in a total of 31 stents placed. In total, 19 stents were 15 x 10 mm and 12 stents were 20 x 10 mm. No intra-procedural complications were noted. The technical success of deployment was 100%. Clinical resolution of symptoms was present in 25 (83%) patients. Of the patients who experienced clinical improvement, 17 underwent stent removal after an average of 6.4 weeks, and clinical recurrence occurred in 7 (41%) patients. The mean time to recurrence of symptoms after stent removal was 7 weeks. Univariate subgroup analysis revealed 15 x 10 mm stents were associated with clinical improvement (OR 12.86, 95% CI: 1.27-130.57, p 0.031). Each patient who did not clinically improve developed pain (3) or stent migration (2). In total 11 (37%) patients developed minor post-procedure adverse event. Stent migration was seen in 5 (17%) cases. Bleeding and pain were noted in 1 (3%) and 7 (23%) patients, respectively. Ulceration was found in 4 patients.
Conclusion(s): LAMS is a durable, safe option for patients with benign luminal strictures. Overall technical success was 100% and clinical success was 83%. The data also suggests better clinical outcomes with 15 x 10 mm stents, when compared to 20 x 10 mm stents. Pain is the most common adverse event but easily managed. [Formula presented]