Surgical endoscopy
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Comparative Study
Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data.
Previous multi-institution comparisons of open and laparoscopic Roux-en-Y gastric bypass (ORYGB and LRYGB), and laparoscopic adjustable gastric banding (LAGB) have been limited by the lack of unique current procedural terminology (CPT) codes. Specific codes have been available for LRYGB and LAGB since 2005 and 2006, respectively. We compare the short-term safety of these procedures, using risk-adjusted clinical data from a multi-institutional quality improvement program. ⋯ Compared with LRYGB, ORYGB is associated with higher 30-day mortality and higher risk-adjusted major complication rate. While ORYGB may sometimes be indicated, a laparoscopic approach may be safer for RYGB when feasible. LAGB, compared with LRYGB, has a similarly low mortality rate and a small but statistically significant decrease in risk-adjusted 30-day complications. Clinical efficacy and long-term outcomes will need to be evaluated to determine superiority between these procedures.
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Comparative Study
A defunctioning stoma significantly prolongs the length of stay in laparoscopic colorectal resection.
Reduction in length of stay has several advantages, including healthcare costs, patient choice, and minimizing hospital acquired infections. Additionally, length of stay is a surrogate marker of rate of recovery from the physiological insult of anaesthesia and surgery and complications thereof. A well-documented short-term benefit of laparoscopic compared to open colorectal resection is reduced length of stay. ⋯ The need for conversion, if performed in a timely and appropriate manner, has little impact on patient outcome compared to those completed laparoscopically, with no significant increase in LOS in our experience. In contrast, a diverting stoma does prolong LOS and some of the benefits of laparoscopic surgery may be lost unless patients requiring a stoma are identified preoperatively and have intensive pre- and postoperative stoma training.
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Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case-control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery. ⋯ Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.
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Review Meta Analysis Comparative Study
Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes.
In recent years, minilaparoscopic cholecystectomy (MLC; total size of trocar incision < 25 mm) has been increasingly advocated for the removal of the gallbladder, due to potentially better surgical outcomes (e.g., better cosmetic result, reduced pain, shorter hospital stay, quicker return to activity), but an evidence-based approach has been lacking. The current systematic review was undertaken to evaluate the importance of total size of trocar incision in improving surgical outcomes in adult laparoscopic cholecystectomy (LC). ⋯ The data included in this review suggest that reducing the size of trocar incision results in some limited improvements in surgical outcomes after LC. However, it carries a higher risk of conversion to conventional LC or open cholecystectomy.
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The project aimed at testing the feasibility of a quality improvement system based on patient-reported outcomes in short-stay surgery for cholecystectomy. ⋯ The low response rate was mainly due to nondelivery of questionnaires at T1 during the regular postoperative visit by the operating physician. Though nonresponse occurs under conditions of routine care, meaningful information was gained, which should be used for quality improvement activities. Because the preoperative level is a major determinant of the postoperative health outcomes, the prospective pre-post measurement should be preferred if institutional comparisons are intended.