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Background Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. Methods The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. Results A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis ( p  = 0.0835) and the most common procedure a sigmoidectomy ( p  = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p  < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p  < 0.0001), complication (32.60 vs. 42.28 %, p  < 0.0001), and mortality rates (0.52 vs. 1.28 %, p  < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p  < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy ( p  < 0.0001), room and board ( p  < 0.0001), recovery room ( p  = 0.0058), ICU ( p  < 0.0001), and laboratory and imaging services (both p  < 0.0001). Surgical supplies ( p  < 0.0001), surgery ( p  < 0.0001), and anesthesia ( p  = 0.0053) were higher for the laparoscopic group. Conclusions Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

Modified frailty index (mFI) has been proposed as a reliable tool in predicting postoperative outcomes after surgery. This study aims to evaluate whether mFI could be utilized to predict readmissions after colorectal resection for patients with cancer by using nationwide cohort. Patients undergoing elective abdominal colorectal resection for colorectal cancer were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure-targeted database (2010–2012). A previously described mFI was calculated. Demographics, comorbidities, and 30-day postoperative complications were compared between patients who were readmitted or not after colorectal surgery. A total of 7337 patients were identified with a mean age of 65.8(±13.6) years. Eight hundred seventy-one (11.8%) patients were readmitted at least once within 30 days. Age, gender, BMI, and other comorbidities were comparable between the groups. O approach, current smoking, mFI(>3/11), disseminating cancer, bleeding disorder and longer operative time were found to independently associated with readmission. An 11-point modified frailty index as measured in NSQIP correlates with readmissions after colorectal resection in patients with colon and rectal cancer. •mFI is a quick and simple tool that can predict readmissions after colorectal surgery.•Open approach, current smoking, disseminating cancer are associated with readmission.•Bleeding disorder and longer operative time are associated with readmission.

Laparoscopic colorectal procedures require specimen extraction. It is unclear whether extraction site affects the incidence of incisional hernia (IH). Patients undergoing laparoscopic colectomy over a 6-year period were identified. Outcomes were compared between patients to evaluate the incidence of hernia. Among 480 laparoscopic colorectal procedures, extraction sites were midline (n = 305), muscle splitting (n = 128), Pfannenstiel (n = 26), and ostomy (n = 21). Average follow-up was 3.5 years. Age, gender, diagnosis, extraction incision length, and hospital stay were similar. The mean body mass index for all patients was 28 kg/m2 and for those with IHs was 31 kg/m2 (P = .008). The overall IH rate was 7%. Midline IHs accounted for 84% of all hernias, occurring in 8.9% of midline extractions (P < .05 vs nonmidline extractions). Hernia rates for muscle-splitting, Pfannenstiel, and ostomy site extractions were 2.3%, 3.8%, and 4.8%, respectively. Although midline hernia rates were lower than traditionally reported with open surgery, midline extraction sites have a higher chance of IH than nonmidline sites.

BackgroundLimited data on the relationship between postoperative complications (POCs) after colorectal cancer resection and oncologic outcomes are available. We hypothesized that the increased severity of POCs is associated with progressively worse oncologic outcomes.MethodsPatients with pathological stages I–III colorectal adenocarcinoma undergoing elective curative resection in a single institution between 2000 and 2012 were identified from a prospectively collected database. The severity of POCs was determined using the Clavien–Dindo classification, and oncologic outcomes were assessed.ResultsOf 2266 patients, 669 (30%) had at least one POC. POCs were not associated with pathologic stage (p = 0.58) or use of adjuvant therapy (p = 0.19). With a mean follow-up of 5.3 years, POCs were associated with decreased 5-year overall survival (OS) (60% vs. 77%, p < 0.001), disease-free survival (DFS) (53% vs. 70%, p < 0.001), cancer-specific survival (CSS) (81% vs. 87%, p < 0.001), and increased overall recurrence rates (19% vs. 15%, p = 0.008). Increasing Clavien–Dindo scores from I to IV was significantly associated with progressively decreasing OS (71, 64, 60, 22%, p < 0.001), DFS (65, 58, 51, 19%, p < 0.001), CSS (88, 77, 79, 74%, p < 0.001), and increasing recurrence rates (12, 20, 26, 18%, p = 0.002). Multivariate analysis confirmed POCs as an independent factor associated with decreased OS [hazard ratio (HR) 0.63, 95% CI 0.52–0.76], DFS (HR 0.64, 95% CI 0.54–0.76), CSS (HR 0.73, 95% CI 0.56–0.97), and increased recurrence rates (HR 1.36, 95% CI 1.02–1.80).ConclusionsPOCs are associated with adverse oncologic outcomes, with increasing effect with higher Clavien–Dindo score. Efforts to reduce both the incidence and severity of complications should result in improved oncologic outcomes.

Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs). One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed. The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%). LC surgery with ERP offers excellent outcomes with efficient use of resources.

Effective, narcotic sparing analgesia is a major component of Enhanced Recovery Protocols (ERP), however the risk of poor analgesia and opioid related side effects (ORADE) remains an issue related to poor outcomes and satisfaction, and is strongly related to the risk of narcotic dependence after surgery. A variety of genes can impact narcotic and non-steroidal (NSAID) drug efficacy including: the CYP family (drug metabolism-narcotics and NSAID), or COMT/ABCB1/OPRM1 (functional receptor and transport activity for analgesia vs side effects). The purpose of this study was to perform the first assessment of the impact of a pharmacogenetics (PGx) guided selection of analgesics following major abdominal surgery within an ERP. A consecutive series of open and laparoscopic colorectal resections or major ventral hernia repair (PGx group) had a guided analgesic protocol based upon assessment of CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, COMT, OPRM1, and ABCB1 genes. Study patients were compared to a recent historical series of patients (H group) managed using our well validated ERP. The primary outcome measure was the Overall Benefit of Analgesia Score (OBAS). Pain scores were also assessed. The data demonstrated a similar mix of procedures and gender between groups and more than half of the PGx group had revised analgesia from the standard ERP. The PGx group demonstrated significantly lower OBAS scores (p = 0.0.1) from POD1 (3.8 vs 5.4) through POD 5 (3.0 vs 4.5) Analgesia was also superior for the PGx group from POD1 through POD 5 (p = 0.04). Pharmacogenetics guidance resulted in frequent modifications of the analgesic program, resulting in excellent analgesia with a 50% reduction in narcotic consumption, and a reduced incidence of analgesic related side effects compared to our standard ERP. These data suggest further improvement in ERP resulting from a patient centric analgesic, reduced narcotic regimen which provides early and durable pain control with fewer narcotic related side effects.

Background Laparoscopic ileal pouch–anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. Methods An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m 2 , diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan–Meier survival curves, uni- and multivariable analyses. Results Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5–17.8) versus 2.4 (0.5–22.2) years in L versus O, respectively ( p  = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1–2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure ( p  = 0.07) or significantly different causes of pouch failure when compared to O. Conclusions Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Background It is unknown if ulcerative colitis (UC) duration has an impact on outcomes of ileal pouch anal anastomosis (IPAA). The aim of the study was to compare the long-term IPAA outcomes based on preoperative UC duration. Methods All patients with pathologically confirmed UC who underwent IPAA were included from a prospectively maintained pouch database (1983–2017).Patient’s cohort was stratified according to UC duration:< 5 years,5–10 years,10–20 years,> 20 years. UC duration was defined as time interval from date of preoperative diagnosis to colectomy date. The main outcome was Kaplan-Meier pouch survival. Secondary outcomes were pouch function and quality of life. Results Out of 4502 IPAAs (1983–2016), 2797 patients were included. Treated with biologics versus 12% with UC duration > 20 years were 41% patients with UC duration < 5 years. Treated with steroids compared to shortest (34%,p < 0.001) were 54% patients with the longest disease. A total of 65% of patients with shortest disease had IPAAs performed mostly in 3 stages. Anastomotic separation and pelvic sepsis were more prevalent among shortest compared to longest disease groups. Rates of pouch-targeted fistulas, anastomotic strictures, and pouchitis were highest in longest disease group. Pouch survival was similar between groups. Multivariate analysis did not show a significant association between UC duration and pouch failure [1.05(0.97–1.1), p = 0.23].Longer UC duration was associated with increased odds of pouchitis [1.2(1.1, 1.3), p < 0.001]. Biologics agents were shown to be protective against pouchitis. Conclusions Preoperative UC duration does not increase pouch failure risk. Longer preoperative UC duration increases the pouchitis risk. Biologic agents and three-staged IPAA are protective against pouchitis and septic complications in long-term among patients with UC.

Background Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy. Our hypothesis was that elderly patients managed with laparoscopic colorectal surgery and an enhanced recovery protocol (ERP) can realize the same benefits of lower hospital length of stay (LOS) without increasing hospital costs or readmission rates. Methods Review of a prospective database identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012. Patients were stratified into elderly (≥70 years old) and nonelderly (<70 years old) cohorts. The main outcome measures were discharge disposition, hospital costs, hospital LOS, and 30-day readmission rates between the laparoscopic and open groups. Results A total of 302 nonelderly (66 %) and 153 elderly (34 %) patients were included in the analysis. The elderly cohort had significantly higher comorbidities than the nonelderly group. There were no mortalities. Operative variables (procedure time, blood loss, and intraoperative complications) were similar. At discharge, significantly more elderly patients required temporary nursing or home care. There were no significant differences in short-term outcomes of LOS, 30-day readmission rates, or costs for the episode of care between the two groups. Conclusions Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients. Despite higher comorbidities, elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates.

Purpose Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy. Methods A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0–39.9), morbidly obese (BMI 40.0–49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay. Results There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P  = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P  = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P  = 0.001), and longer operative times (206 min vs. 184 vs. 163; P  = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P  = 0.027) and MO males (4.1%; P  = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%). Conclusion Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.