Manish M. Tiwari

Comparison of Outcomes of Laparoscopic and Open Appendectomy in Management of Uncomplicated and Complicated Appendicitis

Background:Several studies have demonstrated the superiority of the laparoscopic approach in uncomplicated and complicated appendicitis with conflicting results. As a result the role of laparoscopy in the management of appendicitis in general and complicated or perforated appendicitis, in particular, is still undefined. Methods:A retrospective, observational study design was used to analyze multicenter outcomes using the University HealthSystem Consortium database. A 3-year discharge data of all open appendectomy (OA) and laparoscopic appendectomy (LA) procedures from 2006 to 2008 in adult patients older than 18 years for complicated or uncomplicated appendicitis was accessed using International Classification of Diseases, Ninth Revision codes. Data on several surgical outcome measures such as observed mortality, overall patient morbidity, intensive care unit admission rate, 30-day readmission rate, length of hospital stay, and hospital costs were collected from the University HealthSystem Consortium database. Stratification by University HealthSystem Consortium-specific severity of illness groups and disease diagnosis of complicated or perforated and uncomplicated appendicitis was performed. Results:A total of 40,337 appendectomy procedures performed during 2006 to 2008 in adult patients were included in the study. Laparoscopic appendectomy for uncomplicated appendicitis resulted in significantly better surgical outcomes. However, surprisingly, these outcomes resulted in comparable but not significantly reduced hospital costs (7825 ± 6,009 for LA vs 7841 ± 13,147 for OA; P > 0.05). Laparoscopic appendectomy for complicated or perforated appendicitis showed lower mortality, reduced overall morbidity (17.43% for LA vs 26.68% for OA; P < 0.001), relatively less 30-day readmission rate, fewer intensive care unit admissions, significantly shorter length of hospital stay (4.34 ± 4.84 days for LA vs 7.31 ± 9.43 for OA; P < 0.001), and reduced hospital costs (12,125 ± 14,430 for LA vs 17,594 ± 28,065 for OA; P < 0.001) compared with patients undergoing OA. On stratification for severity of illness in both complicated and uncomplicated appendicitis, laparoscopic appendectomy resulted in a greater or comparable clinical benefit than open appendectomy. Comparable clinical benefit was observed in minor severity patients and moderate and major/extreme severity patients showed vastly improved surgical outcomes with the laparoscopic approach. Conclusions:Laparoscopic appendectomy is superior or comparable to open appendectomy in terms of several surgical outcome measures for both uncomplicated and complicated appendicitis, across most illness severity groups. Thus, laparoscopic appendectomy may be the preferred technique, irrespective of appendicitis diagnosis or disease severity.

Safety, efficacy, and cost-effectiveness of common laparoscopic procedures

BackgroundLaparoscopic surgery has been shown to offer superior surgical outcomes for most abdominal surgical procedures. However, there is hardly any evidence on surgical outcomes with patient risk stratification. This study aimed to compare outcomes of common laparoscopic and open surgical procedures for varying illness severity.MethodsA retrospective analysis of surgical outcomes for six commonly performed surgical procedures including cholecystectomy, appendectomy, reflux surgery, gastric bypass surgery, ventral hernia repair, and colectomy was performed using the University HealthSystem Consortium (UHC) Clinical Database/Resource Manager (CDB/RM). The 3-year discharge data for the six commonly performed laparoscopic surgical procedures were analyzed for outcome measures including observed mortality, overall patient morbidity, intensive care unit (ICU) admissions, 30-day readmissions, length of hospital stay, and hospital costs.ResultsIn this study, 208,314 patients underwent one of six common surgical procedures by either the open or the laparoscopic approach. Overall, the laparoscopic approach showed significantly lower mortality, reduced morbidity, fewer ICU admissions and 30-day readmissions, shorter hospital stay, and significantly reduced hospital costs for all the procedures. At stratification by illness severity, the laparoscopic group showed better or comparable surgical outcomes across all the illness severity groups. However, the observed mortality was comparable for the minor and moderate severity patients between laparoscopic and open surgery for most procedures. The 30-day readmission rate for major/extreme severity patients was comparable between the two groups for most surgical procedures.ConclusionsThis study demonstrated the superiority of laparoscopy over conventional open surgery across all illness severity risk groups for common surgical procedures. The results in general show that laparoscopic surgery is safe, efficacious, and cost-effective compared with open surgery and suggest that laparoscopic surgery should be the procedure of choice for all common surgical procedures, regardless of illness severity.

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives.

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.

Inappropriate use of urinary catheters: a prospective observational study.

BACKGROUND Despite the well-recognized role of urinary catheters in nosocomial urinary tract infections, data on risk factors associated with inappropriate urinary catheter use are scarce. METHODS A prospective review of electronic medical records of 436 patients admitted to an adult medical-surgical unit between October and December 2007 was performed to examine the appropriateness of urinary catheter use. RESULTS The use of 157 urinary catheters in 144 patients was observed. A total of 557 urinary catheter-days were recorded in these patients, of which 175 (31.4%) were found to be inappropriate based on the study criteria. The total number of catheters used and the total duration of catheterization were risk factors for inappropriate urinary catheter use (P < .05). Inappropriate catheter use was not associated with such adverse events as mortality, readmission, intensive care unit admission, catheter complications, or urine culture rates, but was associated with a trend toward longer duration of hospitalization. CONCLUSIONS Significant rates of inappropriate urinary catheter use and a trend toward longer duration of hospitalization with inappropriate catheter use were observed. These findings underscore the importance of establishing guidelines and effective policy implementation for the appropriate use of urinary catheters in hospitalized patients.

Differences in outcomes of laparoscopic gastric bypass

BACKGROUND Although several risk factors affecting weight loss outcomes with bariatric procedures have been identified, the effect of age, gender, race, and illness severity on postoperative outcomes of laparoscopic gastric bypass has not been extensively examined. METHODS The University HealthSystem Consortium database is an administrative and financial database that provides information on the inpatient stay. A retrospective analysis of patient outcomes was performed using 4-year discharge data from the University HealthSystem Consortium database. RESULTS A total of 37,765 patients underwent laparoscopic gastric bypass. The women exhibited significantly reduced mortality, morbidity, intensive care unit (ICU) admissions (9.87% male versus 6.73% female; P <.001), duration of hospitalization (2.72 ± 4.03 d for men versus 2.59 ± 2.88 d for women; P <.001), and hospital costs (

Inappropriate intravascular device use: a prospective study

17,346 ±

Accuracy and speed trade-off in robot-assisted surgery

15,397 for men versus

Primary and revisional laparoscopic adjustable gastric band placement in patients with hiatal hernia

14,383 ±

Recent advances in the CoBRASurge robotic manipulator and dexterous miniature in vivo robotics for minimally invasive surgery

11,170 for women; P <.001). Blacks demonstrated significantly greater 30-day readmission rates, duration of hospitalization, and costs compared with whites. Hispanics had lower ICU admission and hospital costs compared with whites. With increasing age, an increased risk of overall morbidity, ICU admissions, duration of hospitalization, and costs was observed. Compared with the minor severity group, the major/extreme severity group had significantly greater observed mortality, overall morbidity, ICU admissions, duration of hospitalization, and hospital costs. CONCLUSION The present study identified gender, race, age, and illness severity as risk factors affecting postoperative outcomes after laparoscopic gastric bypass. Male gender and increasing age were overall associated with an increased risk of complications. Significant racial disparities in the outcome measures were observed with blacks having an increased risk of adverse events. Illness severity was shown to adversely affect the surgical outcomes in laparoscopic gastric bypass.

Not all biologics are equal

Despite the clinical significance of complications due to intravascular catheters, the inappropriate use of intravascular catheters in hospitalised patients has not been adequately characterised. The objective of this prospective observational study was to develop definitions for appropriate intravascular device use, to estimate the frequency of inappropriate use of intravascular devices, and to examine risk factors and outcomes associated with inappropriate use in hospitalised patients. Among 436 patients admitted between October and December 2007, a total of 2909 hospitalisation days and use of 876 intravascular devices was observed. Of the 3806 total catheter-days recorded, 1179 (31%) were found to be inappropriate based on the study criteria. Logistic regression analysis indicated that age, total number of catheters used and total duration of catheterisation were risk factors for inappropriate device use (P<0.05). Inappropriate usage was strongly associated with increased intensive care unit admission (P<0.05) and length of hospital stay (4.9±4.3 days for appropriate vs 8.5±12.6 days for inappropriate; P<0.05). Use of central venous catheters was not a predictor for inappropriate device use. Inappropriate intravascular device use is a very common phenomenon in hospitalised patients and is strongly linked to adverse device-related outcomes. These results may be used to develop strategies to systematically reduce excessive intravascular device use which would be expected to reduce adverse events associated with morbidity, mortality, and excess healthcare costs.