Conor P. Delaney

Evaluation of the Learning Curve in Laparoscopic Colorectal Surgery: Comparison of Right-Sided and Left-Sided Resections

Objective:To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. Summary Background Data:The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. Methods:This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. Results:The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeons experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. Conclusions:Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection.

AbstractINTRODUCTION: In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice. METHODS: Sixty-four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol. RESULTS: Pathway patients spent less total time in the hospital after surgery (5.4 vs. 7.1 days; P = 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5 vs. 7.1 days; P = 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P = 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay. CONCLUSIONS: Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome.

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

CONTEXT The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. OBJECTIVE To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. DESIGN, SETTING, PARTICIPANTS A retrospective cohort study, using Premier Incs Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. MAIN OUTCOME MEASURE The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. RESULTS There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. CONCLUSIONS Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery

BACKGROUND Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. METHODS Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. RESULTS A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] -3.92 to -1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36-0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14-1.43) when compared with patients undergoing traditional care. CONCLUSION Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.

Comparison of Robotically Performed and Traditional Laparoscopic Colorectal Surgery

Robotic laparoscopic surgery is postulated to result in better surgical results by allowing improved instrument manipulation and three-dimensional vision. The authors’ experience performing robot-assisted laparoscopic colorectal surgery is reported. METHOD: Standard laparoscopic procedures with robot-assisted laparoscopic colon mobilization and vascular ligation were performed. Data relating to the operative procedure, hospital stay, and direct costs were collected. Results were compared with age, gender, and procedure case-matched controls taken from a prospective laparoscopic colorectal surgery database. RESULTS: Six robot-assisted laparoscopic surgeries (2 right hemicolectomies, 3 sigmoid colectomies, and 1 Wells rectopexy) were performed between December 2001 and June 2002. There was no associated morbidity. Operative time was increased from a median time of 108 minutes for standard laparoscopic colorectal surgery to 165 minutes for robot-assisted laparoscopic surgeries (P = 0.0313; Wilcoxon matched-pairs signed-rank test for non-parametric data). This was primarily a result of the time required for robot set-up. Blood loss, length of stay, and hospital cost were not significantly different between groups. Additional direct equipment costs for RAC cases included robotic laparoscopic instruments and sterile drapes (approximately US

Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? ☆: Laparoscopy versus laparotomy

350 per case), without including acquisition and maintenance costs for the robot. CONCLUSION: Robot-assisted laparoscopic colectomy is a feasible and safe procedure. Although three-dimensional vision and dexterity are facilitated, operative time is increased and the overall additional expense of robotics is of concern. Robot-assisted laparoscopic colectomy requires further evaluation to establish clinical and financial benefits before introduction to routine practice. Such techniques may, in the future, facilitate complex laparoscopic techniques.

Clinical Outcomes and Resource Utilization Associated With Laparoscopic and Open Colectomy Using a Large National Database

BACKGROUND Laparotomy for bowel resection is causally related to the development of small bowel obstruction (SBO) and ventral hernia, with incidences approaching 12% to 15% each. This report attempts to define the incidence of these access-related complications in a large group of patients undergoing laparoscopic-assisted bowel resection (LABR) and open bowel operation (OPEN). STUDY DESIGN A retrospective cohort of 716 consecutive patients undergoing either LABR (n = 211) or OPEN (n = 505) procedures between January 1995 and July 2000 was identified and selected from a prospective registry. RESULTS Index LABR (n = 211) and OPEN (n = 505) cases included segmental colectomy in 146 LABR and 408 OPEN patients; subtotal colectomy with or without stoma in 18 LABR and 6 OPEN patients; ileocolectomy in 37 LABR and 85 OPEN patients; and small bowel resection in 10 LABR and 6 OPEN patients. The mean followup periods in the LABR and OPEN groups were 2.71 years and 2.42 years, respectively. The incidence of wound hernia was significantly higher in OPEN cases (n = 65) compared with LABR (n = 5) (p < 0.05). The incidence of surgical repair of ventral hernia was also significantly higher in the OPEN group (28) compared with LABR (4) (p < 0.05). Postoperative SBO requiring hospitalization with conservative management occurred significantly less frequently in LABR patients (n = 4) compared with OPEN patients (n = 31) (p = 0.016). The need for surgical release of SBO was similar between the OPEN and LABR groups (n = 4 versus n = 11). The overall reoperation rate for these two complications was two times higher in the OPEN group than in the LABR group (7.7% versus 3.8%). CONCLUSIONS The data demonstrate that laparoscopic access for bowel operation significantly reduces the incidence of ventral hernia and SBO rates compared with laparotomy. This reduces the need for readmission to the hospital and additional surgical procedures, providing a potential source of decreased morbidity. It should be considered as a means of cost savings associated with laparoscopic bowel operations.

Prospective, Age-Related Analysis of Surgical Results, Functional Outcome, and Quality of Life After Ileal Pouch-Anal Anastomosis

Objectives:To clarify national clinical and economic laparoscopic colectomy outcomes, we conducted a study of patients who underwent colectomy by laparoscopic or open approaches. Background:Laparoscopy is becoming the preferred approach for colectomy in benign and malignant diseases. Although it is associated with significant clinical benefits, economic outcomes have varied. Methods:We analyzed cohorts of patient-level data from Premier Inc.s Perspective Rx Comparative Database, which collects data from more than 500 hospitals throughout the United States. By reviewing hospital charge data, patients who underwent elective colectomies from July 1, 2004, through June 30, 2006, were identified using International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. The colectomy had to be listed as the primary or secondary procedure of the hospitalization. Primary outcomes included transfusion rates, in-hospital complications, readmissions within 30 days, reoperations, length of stay, total hospitalization costs, and discharge dispositions and services. Results:We identified 32,733 patients who had elective colectomies throughout 402 hospitals; 11,044 (33.7%) were laparoscopic and 21,689 (66.3%) were open colectomies. The mean age was 64.2 ± 13.9 years and 53.8% were women. Laparoscopic colectomy patients had a longer mean operative time (195 ± 76 vs. 178 ± 80 minutes; P < 0.0001) and higher total hospital costs (

Case-Matched Comparison of Clinical and Financial Outcome after Laparoscopic or Open Colorectal Surgery

8076 vs.

Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: Similarities and differences

7678; P = 0.0002). Laparoscopic patients had shorter mean length of stay (7.0 vs. 8.1; P < 0.0001) and fewer mean intensive care unit days (0.7 ± 3.8 vs. 1.3 ± 5.2 days; P < 0.0001). The laparoscopic cohort also had lower rates of transfusions (odds ratio [OR] = 0.68; P < 0.0001), in-hospital complications (OR = 0.89; P < 0.0001), and readmissions within 30 days (OR = 0.89; P = 0.0051), although reoperation rates were slightly, but significantly increased (OR = 1.78; P = 0.002). Laparoscopic colectomy patients were more likely to be discharged home without nursing care (OR = 0.70; P < 0.0001). Conclusion:Evaluation of a national administrative data set showed that patients who underwent laparoscopic colectomy had shorter intensive care unit and total hospital stays, fewer complications, lower mortality, fewer readmissions, and less use of skilled nursing facilities after discharge. There was a small but significant increase in reoperation rates and in-hospital costs with laparoscopic colectomy. Improved application of enhanced recovery programs and operative efficiencies may further improve resource utilization associated with laparoscopic colectomy.