Disparities in the use of minimally invasive surgery for colorectal disease.
ABSTRACT Morbidity and mortality rates for major surgical procedures are decreased in high-volume hospitals (HVH). Additionally, HVH are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS). Although HVH often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at HVH.
Laparoscopic and open colectomies performed at HVH were identified using the 2008 Nationwide Inpatient Sample database. ICD-9 codes were used to identify MIS colorectal resections. Multiple logistic regression including ethnic and socioeconomic variables were used to identify independent predictive factors for undergoing MIS.
A total of 211,862 colorectal resections were performed at HVH in 2008. Only 16,637 (7.3%) colorectal resections were performed using MIS. When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo MIS than those in the lowest income groups. In addition, patients with Medicaid and uninsured patients were significantly less likely to undergo MIS compared to patients with private insurance. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH.
There are significant socioeconomic disparities in the use of MIS for colorectal disease at HVH. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.
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ABSTRACT: Background. The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. Methods. We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparosccrpy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. Results. A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). Conclusion. During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.Surgery 07/2014; 156(3). DOI:10.1016/j.surg.2014.03.046 · 3.11 Impact Factor
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ABSTRACT: Background: High socioeconomic status is associated with better survival in colorectal cancer (CRC). This study investigated whether socioeconomic status is associated with differences in surgical treatment and mortality in patients with CRC. Methods: Patients diagnosed with stage I-III CRC between 2005 and 2010 in the Eindhoven Cancer Registry area in the Netherlands were included. Socioeconomic status was determined at a neighbourhood level by combining the mean household income and the mean value of the housing. Results: Some 4422 patients with colonic cancer and 2314 with rectal cancer were included. Patients with colonic cancer and high socioeconomic status were operated on with laparotomy (70.7 versus 77.6 per cent; P = 0.017), had laparoscopy converted to laparotomy (15.7 versus 29.5 per cent; P = 0.008) and developed anastomotic leakage or abscess (9.6 versus 12.6 per cent; P = 0.049) less frequently than patients with low socioeconomic status. These differences remained significant after adjustment for patient and tumour characteristics. In rectal cancer, patients with high socioeconomic status were more likely to undergo resection (96.3 versus 93.7 per cent; P = 0.083), but this was not significant in multivariable analysis (odds ratio (OR) 1.44, 95 per cent confidence interval 0.84 to 2.46). The difference in 30-day postoperative mortality in patients with colonic cancer and high and low socioeconomic status (3.6 versus 6.8 per cent; P < 0 001) was not significant after adjusting for age, co-morbidities, emergency surgery, and anastomotic leakage or abscess formation (OR 0.90, 0.51 to 1.57). Conclusion: Patients with CRC and high socioeconomic status have more favourable surgical treatment characteristics than patients with low socioeconomic status. The lower 30-day postoperative mortality found in patients with colonic cancer and high socioeconomic status is largely explained by patient and surgical factors.British Journal of Surgery 08/2014; 101(9). DOI:10.1002/bjs.9555 · 5.21 Impact Factor
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ABSTRACT: After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.World Journal of Gastroenterology 02/2014; 20(7):1777-1789. DOI:10.3748/wjg.v20.i7.1777 · 2.43 Impact Factor