Article 1
Robotic colorectal surgery in the emergent diverticulitis setting: is it safe? A review of large national database. Curfman KR, JonesIF, Conner JR, Neighorn CC, Wilson RK, Rashidi L. International Journal of Colorectal Disease. 2023 May 25;38(1):142.
Background:
The historical standard for emergency surgery in acute diverticulitis disease has been open surgery (OS) with Hartmann’s procedure. With advancements in minimally invasive surgery and the proliferation of robotic surgery, there has been a shift towards less invasive approaches, specifically laparoscopic surgery (LS) and/or robotic surgery (RS). With a nationwide increase in the use of robotic surgery for elective and emergent surgeries, this retrospective study aims to compare outcomes of emergent surgery for diverticular disease performed with different approaches (OS vs. LS vs. RS).
Study Design:
Data were collected retrospectively from a custom hospital analytics database consisting of de-identified data from 262 facilities and 1130 surgeons over a 3-year period from 2018-2021. The study included 2524 patients who underwent emergency surgery for diverticulitis: OS 1952 (77%), LS 446 (18%), and RS 126 (5%). Outcomes were analyzed, including length of stay, complication rates, and conversion rates.
Findings:
Compared to OS, RS had a decrease in rates of ICU admission (19% vs. 9%; p=0.01), decreased anastomotic leak rates (4% vs. 0.8%; p=0.04), and improved length of stay (10 days vs. 9 days; p=0.05). Mortalities (1.46% vs. 0.81%) and surgical site infections (2.1% vs. 1.6%) were similar in both OS and RS groups. Compared to LS, RS had a slight decrease in rates of ICU admission (11% vs. 9%; p=0.5), decreased anastomotic leak rates (4% vs. 0.8%; p=0.04), and a similar length of stay (9 days). Mortalities (0.9% vs. 0.8%) and surgical site infections (1.3% vs. 1.6%) were similar in both LS and RS groups. Conversion rates were remarkably different between LS (28.7%) and RS (7.9%) groups. To provide correlation with surgeon experience, authors found that surgeons who performed OS averaged 16.2 robotic surgeries per year, compared to surgeons who performed LS, averaged 27.3 robotic surgeries per year, and surgeons who performed RS averaged 63 robotic surgeries per year.
Limitations:
Limitations of the study include the retrospective administrative database nature of the study along with the potential for coding errors and the inability to comprehensively assess disease severity and patient co-morbidities.
Conclusion:
Robotic surgery has clear advantages over traditional laparoscopic surgery, with a stable camera platform, three-dimensional imaging, improved ergonomics, tremor elimination, ambidextrous capabilities, and instrument range of motion. Authors of this study demonstrate that using the robotic platform to perform emergent diverticulitis surgery is a safe and feasible alternative to laparoscopic and open approaches with improvements in certain outcomes. As demonstrated by this paper, surgeons who frequently perform robotic surgeries for elective colorectal surgeries tend to opt for the robotic platform when dealing with emergent colorectal surgeries, and this may explain reduced conversion rates and improved anastomotic leak rates. However, some of the barriers to widespread adoption are surgeon experience, longer operative time with the robot platform, a lack of trained operating room staff during after hours, and a lack of protocols for the appropriate use of robotic surgery during emergent settings.
Article 2
The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients. Zogg CK, Falvey JR, Kodadek LM, Staudenmayer KL, Davis KA. J Trauma Acute Care Surg. 2024 Mar 1;96(3):400-408.
Older adults (>65 years of age) are at high risk for adverse outcomes after admission for emergency general surgery (EGS) conditions owing to due to factors related to advanced age (ie. “geriatric vulnerability”). It is further known that where a person lives affects their baseline EGS mortality risk (ie. “neighborhood vulnerability”). In their paper, Zogg et al. seek to determine how these two pre-admission factors interact – specifically, the degree to which mortality risk due to geriatric vulnerability is influenced by neighborhood vulnerability. As a secondary objective, they also evaluate the impact of racial/ethnic minority status on this relationship. To accomplish this, the authors use the Florida State Inpatient Database (2016–2021, 2020 excluded due to COVID-19). Older adults diagnosed with 1 of 16 common EGS conditions were included. Measures of neighborhood vulnerability analyzed were the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI). To define geriatric vulnerability, the authors take the unique approach of using a Bayesian latent variable model to combine the influences of age, frailty, and multimorbidity into a single measure, operationalized into quintiles. Hierarchical survival models were then used to measure the association between geriatric vulnerability and mortality (30- and 365-day), stratified by neighborhood vulnerability (ADI and SVI) and racial/ethnic minority status.
Over the 5 years studied 448,968 older adults were treated for EGS conditions at 219 hospitals. After risk-adjustment, patients in the highest quintile of geriatric vulnerability were at 14-fold higher risk of death at 30 days (HR 14; 95%CI 13–16). This association was significantly modified by neighborhood vulnerability. Specifically, the magnitude of increase in risk of death associated with the highest geriatric vulnerability was more than 2-fold greater for individuals residing in neighborhoods in the highest ADI quintile (HR 15; 95%CI 13–18) compared to individuals residing in neighborhoods in the lowest ADI quintile (HR 6; 95%CI 4–9). This interaction was compounded even greater by racial/ethnic minority status. For patients among this group, the magnitude increase in risk of death associated with highest geriatric vulnerability was 4-fold greater for individuals residing in neighborhoods with highest (HR 41; 95%CI 23–73) compared to lowest ADI (HR 12; 95%CI 5–29). These findings were consistent for the outcome of 365-day mortality. Limitations of the study include use of administrative claims data from a single state, which may not be generalizable across populations in the United States. The use of area-level deprivation indices, essentially ecologic measures, lack the ability to discern events at the individual person level. Nonetheless, the findings are both alarming and not surprising. As the population ages, there is need to both elucidate, and design systems to correct, the manner in which structural and historical disparities place patients at increased risk of adverse outcomes after acute surgical emergencies.
