Swedish Medical Center, Swedish Cancer Institute, 1101 Madison St. # 510, Seattle, WA, 98104, USA.
MD Anderson Cancer Center, Baptist Health, Jacksonville, FL, USA.
Surg Endosc. 2020 Feb;34(2):598-609. doi: 10.1007/s00464-019-06804-z. Epub 2019 May 6.
Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.
The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.
The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.
Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.
微创外科方法治疗憩室病的益处受到转换为开放手术的限制。对包括转换风险因素的全面分析可能会改善患者的结局。
利用美国 Premier Healthcare Database 数据库，确定了 2013 年至 2015 年 9 月期间接受原发性择期乙状结肠切除术治疗憩室病的患者。使用倾向评分匹配比较腹腔镜和机器人辅助乙状结肠切除术的转换率。使用多变量逻辑回归分析与转换相关的患者、临床、医院和外科医生特征，提供比较风险的优势比。比较微创手术中转、完成和开放病例的手术结果，评估临床和经济影响。
研究人群包括 13240 例乙状结肠切除术患者（8076 例腹腔镜，1301 例机器人辅助，3863 例开放）。对倾向评分匹配患者的分析显示，腹腔镜手术（13.6%）的转换率高于机器人辅助手术（8.3%）（p < 0.001）。与白人相比，黑人患者、医疗补助保险患者相比商业保险患者、Charlson 合并症指数≥2 患者相比 0 患者、肥胖患者、伴有结肠切除术患者、伴有腹膜脓肿或瘘管患者、或粘连松解患者的转换风险更高。与腹腔镜手术相比，机器人辅助乙状结肠切除术（OR 0.58）、手辅助手术、更高的外科医生手术量和结直肠专业外科医生与转换风险降低显著相关。与微创手术完成和开放病例相比，中转病例的手术室时间、住院时间和术后并发症更多。与微创手术完成病例相比，中转病例的再入院率和输血率更高，与开放手术相似。与微创手术完成病例相比，中转病例的通胀调整总费用（4971 美元）、直接费用（2760 美元）和间接费用（2212 美元）显著更高。
憩室病微创转为开放乙状结肠切除术会导致更多的发病率和医疗保健费用。考虑转换的可改变风险因素可能会减轻不良相关结局。
