Use of laparoscopy in general surgical operations at academic centers

Surgery for Obesity and Related Diseases 9 (2013) 15 20 Original article Use of laparoscopy in general surgical operations at academic centers Ninh T. Nguyen, M.D. a, *, Brian Nguyen, B.S. a, Anderson Shih, B.S. a, Brian Smith, M.D. a, Samuel Hohmann, Ph.D. b a Department of Surgery, University of California, Irvine, Medical Center, Orange, California b University HealthSystem Consortium, Chicago, Illinois Received May 16, 2012; accepted July 6, 2012 Abstract Keywords: Background: Laparoscopy is commonly being used in many different types of general surgical procedures. The aim of the present study was to examine the use of laparoscopy and perioperative outcomes in 7 general surgical operations commonly performed at U.S. academic medical centers. Methods: The clinical data of patients who underwent 1 of the 7 general surgical operations from 2008 to 2012 were obtained from the University HealthSystem Consortium database. The University HealthSystem Consortium database contains data from all major teaching hospitals in the United States. The 7 analyzed operations included only elective, inpatient procedures (except for appendectomy): open and laparoscopic antireflux surgery for gastroesophageal reflux, colectomy for colon cancer or diverticulitis, bariatric surgery for morbid obesity, ventral hernia repair for incisional hernia, appendectomy for acute appendicitis, rectal resection for rectal cancer, and cholecystectomy for cholelithiasis. The outcome measures included the number of procedures, rate of laparoscopy, rate of conversion to laparotomy, and in-hospital mortality. Results: During the 3.5-year period, 53,958 patients underwent bariatric surgery, 13,918 patients underwent antireflux surgery, 8654 patients underwent appendectomy, 8512 patients underwent cholecystectomy, 29,934 patients underwent colectomy, 17,746 patients underwent ventral hernia repair, and 4729 patients underwent rectal resection. The present rate of laparoscopic use was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In-hospital mortality was greatest for colorectal resection (.38%.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that for appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.20%). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%). Conclusion: Within the context of academic centers and elective, inpatient procedures, bariatric surgery had the greatest use of laparoscopy and the lowest rate of laparoscopic conversion to open surgery. The mortality for laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery. (Surg Obes Relat Dis 2013;9:15 20.) 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. Bariatric surgery; Use of laparoscopy; Laparoscopy; Cholecystectomy Presented at the American Society for Metabolic and Bariatric Surgery Annual Meeting, June 20, 2012, San Diego, CA. *Correspondence: Ninh T. Nguyen, M.D., Department of Surgery, University of California, Irvine, Medical Center, 333 City Building West, Suite 850, Orange, CA 92868. E-mail: ninhn@uci.edu Laparoscopy has revolutionized how surgeons perform general surgical operations. First described in 1989 with laparoscopic cholecystectomy, laparoscopy was soon applied to many other operations, including appendectomy, antireflux surgery, ventral hernia repair, colorectal surgery, and, even, bariatric surgery [1]. Compared with traditional open surgery, laparoscopic surgery is often associated with 1550-7289/13/$ see front matter 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2012.07.002

16 N. T. Nguyen et al. / Surgery for Obesity and Related Diseases 9 (2013) 15 20 lower postoperative pain, a shorter length of hospital stay, and lower morbidity, particularly lower wound-related complications, such as surgical site infection and late ventral hernia [2]. Morbid obesity was once a relative contraindication for laparoscopy; however, laparoscopic bariatric surgery is now the standard of care for the treatment of morbid obesity [3]. The aim of the present study was to examine the use of laparoscopy, the rate of laparoscopic conversion to open surgery, and the perioperative outcomes among 7 general surgical operations commonly performed at U.S. academic medical centers. Methods Discharge data set The University HealthSystem Consortium (UHC) database is an administrative, clinical, and financial database that provides benchmark measures for the use of healthcare resources for the purpose of comparative data analysis among academic institutions. The UHC database is a collection of patient-level, abstracted data from academic health centers and affiliate community hospitals. It contains discharge information on the inpatient hospital stay, including patient characteristics, length of stay, overall and specific postoperative morbidity, and observed and expected (risk-adjusted) in-hospital mortality. In-hospital mortality was defined as the percentage of patients who died before being discharged from the hospital. The UHC database has no information available on mortality occurring after discharge, even if the death occurred within 30 days after the date of surgery. The institutional review board of the University of California, Irvine, Medical Center and the UHC approved the use of the UHC patient-level data in the present study. Study cohort We analyzed the UHC hospital discharge records of all patients who had undergone any of the 7 commonly performed general surgical procedures with defined codes for laparoscopic and open procedures from October 1, 2008 to March 1, 2012. We examined only elective cases that were performed on an inpatient basis. However, for appendectomy, we analyzed both elective and urgent cases. Analysis of the 7 general surgical procedures required the use of appropriate diagnosis and procedure codes as specified by the International Classification of Diseases, 9th revision (ICD-9), Clinical Modification (Table 1). These procedures included bariatric surgery (laparoscopic or open gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding) for the treatment of morbid obesity, laparoscopic Table 1 International Classification of Diseases, 9th Revision diagnosis and procedural codes for 7 commonly performed general surgical operations Operation Diagnosis code Procedural code Bariatric surgery Obesity unspecified (27800) Morbid obesity (27801) Cholecystectomy Calculus of gallbladder with other cholecystitis (5741, 54710, 57411) Calculus of gallbladder without mention of cholecystitis (5742, 57420) Antireflux surgery Esophagitis (5301, 53010, 53011, 53012, 53019) Esophageal reflux and Barrett s (53081, 53085) Diaphragmatic hernia (5533) Laparoscopic gastric banding (4495) Laparoscopic gastric bypass (4438) Laparoscopic gastroplasty (4468) Laparoscopic vertical sleeve gastrectomy (4382) Open gastric bypass (4431, 4439) Laparoscopic cholecystectomy (5123) Open cholecystectomy (5121, 5122) Laparoscopic esophagogastroplasty and repair of diaphragmatic hernia (4467, 5371) Open esophagogastroplasty and repair of diaphragmatic hernia (4465, 4466, 5372, 5375) Appendectomy Acute appendicitis (540, 5409) Laparoscopic appendectomy (4701) Open appendectomy (4709, 470) Colectomy Neoplasm of colon (153, 1530, 1531, 1532, 1533, 1534, 1535, 1536, 1537, 1538, 1539) Diverticulitis of colon (56210, 56211, 56212, 56213, 5621) Laparoscopic colectomy (1736, 1735, 1739, 1734, 1733, 1732, 4581) Open colectomy (4573, 4575, 458, 4582, 4583, 4572, 4574, 4576, 4579) Ventral hernia repair Ventral hernia without obstruction or gangrene (5532, 55320, 55321, 55329) Rectal resection Neoplasm of rectum (154, 1540, 1541, 1542, 1543, 1548, 20917, 20,957, 2304) Benign neoplasm (2114) Laparoscopic umbilical/incisional hernia repair (5342, 5343, 5362, 5363) Open umbilical/incisional hernia repair (5369, 5361, 5359, 5341) Laparoscopic pull-through or abdominoperineal resection of rectum (4842, 4851) Open pull-through or abdominoperineal resection of rectum (4840, 4843, 4849, 4850, 4852, 4859, 4862, 4866, 4869)

Use of Laparoscopy in General Surgery / Surgery for Obesity and Related Diseases 9 (2013) 15 20 17 Table 2 Patient demographics Demographics Bariatric Antireflux Appendectomy (both urgent and elective) Cholecystectomy Colectomy Ventral hernia repair Rectal resection Patients (n) 53,958 13,918 8654 8512 29,934 17,749 4729 Age group (n) 45 yr 27,677 (51.5) 4041 (29.0) 6884 (79.6) 3331 (39.1) 3624 (12.1) 3968 (22.4) 520 (11.0) 45 yr 26,057 (48.5) 9877 (71.0) 1770 (20.4) 5181 (60.9) 26,310 (87.9) 13,781 (77.6) 4209 (89.0) Female gender (n) 41,719 (77.6) 24,459 (77.7) 3729 (43.1) 5780 (67.9) 15,559 (52.0) 9831 (55.4) 1841 (38.9) Race (n) White 38,638 (71.9) 11,584 (83.2) 4699 (54.3) 4957 (58.2) 22,731 (75.9) 13,682 (78.1) 3611 (76.4) Black 8802 (16.4) 943 (6.8) 781 (9.0) 1514 (17.8) 3353 (11.2) 1971 (11.1) 472 (10.0) Other 6294 (11.7) 2078 (10.0) 3174 (36.7) 2041 (24.0) 3850 (12.9) 2096 (11.8) 640 (13.7) Severity class (n) Minor 30,681 (57.1) 9819 (70.5) 7180 (83.0) 3918 (46.0) 12,314 (41.1) 9058 (51.0) 1983 (41.9) Moderate and major 23,053 (42.9) 4099 (29.5) 1474 (17.0) 4594 (54.0) 17,620 (58.9) 8691 (49.0) 2791 (58.1) Data in parentheses are percentages. or open cholecystectomy for cholelithiasis, laparoscopic or open antireflux surgery for esophageal reflux, laparoscopic or open appendectomy for acute appendicitis, laparoscopic or open colectomy for cancer or diverticulitis, laparoscopic or open ventral hernia repair for umbilical or incisional hernia, and laparoscopic or open rectal resection for cancer. The decision to analyze these 7 specific operations was because of the availability of both laparoscopic and open ICD-9 procedural codes for each of these operations. The specific ICD-9 procedure codes for laparoscopic sleeve gastrectomy only first became available on October 1, 2011. The specific ICD-9 procedure codes for laparoscopic colorectal resection first became available on October 1, 2008. Laparoscopic cases that were converted to open surgery were identified by the ICD-9 diagnosis code V64.41, representing laparoscopic procedures converted to an open approach. The primary outcomes of the present study were to examine the rate of laparoscopy and the rate of laparoscopic conversion to open surgery for the different procedures. The rate of laparoscopy was calculated by dividing the number of laparoscopic procedure by the total number of procedures (laparoscopic and open). Secondary outcomes include inhospital mortality, length of stay, and overall in-hospital complications. Results The demographics of the patients undergoing the 7 general operations are listed in Table 2. Patients undergoing colorectal surgery tended to be older and to have more moderate and major severity of illness. The use of laparoscopy among the 7 different general surgical operations is depicted in Figure 1. The rate of laparoscopy was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In 2009, laparoscopic colectomy exceeded that of open colectomy (50.3% versus 49.7%, respectively). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%). For bariatric surgery, the rate for conversion was greatest for laparoscopic gastric bypass (2.5%), followed by laparoscopic vertical sleeve gastrectomy (.11%) and laparoscopic gastric banding (.07%). In-hospital mortality, length of hospital stay, and overall in-hospital complications are listed in Table 3. In-hospital mortality for the 7 commonly performed general surgical operations is shown in Figure 2. In-hospital mortality was greatest for colorectal resection (.38%.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that of appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.2%). Discussion Data from a large cohort of patients who underwent 7 commonly performed inpatient general surgical operations at academic medical centers from 2008 to 2012 showed the greatest usage of laparoscopy for bariatric surgery and the lowest for rectal resection. The in-hospital mortality for bariatric surgery was comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery. In the present study, we found 4 general surgical operations with 75% laparoscopic use: bariatric surgery, antireflux surgery, appendectomy, and cholecystectomy. Among these 4 operations, the use of laparoscopy was greatest for bariatric surgery (94%). Several prospective trials have shown the clinical benefits of laparoscopic gastric bypass compared with open gastric bypass, including a reduced rate of wound infection and ventral hernia repair, major advantages for the morbidly obese patient [2,3]. The rate of laparoscopic use for bariatric surgery has exceeded that of antireflux surgery

18 N. T. Nguyen et al. / Surgery for Obesity and Related Diseases 9 (2013) 15 20 100% Rate of laparoscopy 80% 60% 40% 20% 0% Bariatric surgery Antireflux surgery Appendectomy Cholecystectomy Colectomy Ventral hernia repair General surgical operations, 2008-2012 Rectal resection Fig. 1. Rate of laparoscopic utilization among seven common general surgical operations, 2008 2012. and cholecystectomy. Laparoscopic use of antireflux surgery is now commonly performed by most surgeons; however, the use of laparoscopy for repair of paraesophageal hiatal hernia is dependent on the size of the hernia and the surgeon s experience with complex laparoscopic foregut surgery. The rate of laparoscopic conversion to open laparotomy was lowest for bariatric surgery, antireflux surgery, and appendectomy and greatest for cholecystectomy and colorectal resection. The high rate of conversion to open laparotomy in colectomy and rectal resection might be related to the learning curve with the laparoscopic technique, because 2009 was the first year that laparoscopic colectomy exceeded that of open colectomy. The high rate of laparoscopic conversion associated with cholecystectomy might be related to the presence of acute inflammation or the need for common bile duct exploration. The interval from the initial description of the laparoscopic procedure to significant adoption (by 50%) resulted from the complexity of the procedure and other factors (Fig. 3). Laparoscopic cholecystectomy was first reported in 1989 [1]. By 1992, the use of the laparoscopic approach for urgent cholecystectomy exceeded that of the open approach [4]. Shortly after the first report of laparoscopic cholecystectomy, laparoscopic antireflux surgery was reported in 1991 [5]. By 1996, Finlayson et al. [6] reported that the rate of laparoscopic antireflux surgery exceeded that of open antireflux surgery. In 1997, 64% of antireflux operations were performed using the laparoscopic approach [6]. For bariatric surgery, laparoscopic gastric bypass for the treatment of morbid obesity was first reported by Wittgrove et al. [7] in an initial publication in 1994 with a small series of 5 cases. Unlike laparoscopic cholecystec- Table 3 Use of laparoscopy, rate of conversion to open surgery, and outcomes of laparoscopic procedures Operations Patients (n) Laparoscopy (%) Conversion rate (%) LOS (d) Overall complication rate* (%) In-hospital mortality rate* (%) Bariatric surgery 53,958 94.0.89 2.26 3.19 2.2.06 Antireflux surgery 13,918 83.7 2.66 2.80 3.25 4.1.15 Appendectomy 8654 79.2 2.35 1.66 1.38.8.01 Cholecystectomy 8512 77.1 14.6 2.03 2.29 3.6.27 Colectomy 29,934 52.4 13.5 5.34 4.26 6.4.38 Ventral hernia repair 17,749 28.1 6.55 3.05 2.66 2.6.20 Rectal resection 4729 18.3 16.4 7.04 4.68 10.0.58 LOS length of stay. * Outcome of laparoscopic operations. Urgent and elective cases.

Use of Laparoscopy in General Surgery / Surgery for Obesity and Related Diseases 9 (2013) 15 20 19 0.70% In-hospital mortality rate 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% Rectal resection Colectomy Cholecystectomy Ventral hernia repair Antireflux surgery Bariatric surgery Appendectomy General surgical operations, 2008-2012 Fig. 2. In-hospital mortality for general surgical operations, 2008-2012. tomy, laparoscopic gastric bypass is a complex gastrointestinal operation requiring resection and reconstruction and is performed in morbidly obese patients. By 1999, some use of laparoscopic gastric bypass was evident, but it was not until 1 decade later (2004 2006), when Nguyen et al. [3] reported on their series, that bariatric surgery shifted to a predominately laparoscopic approach. Laparoscopic appendectomy was first reported by Semm [8] in 1983. However, it was not until the series by Masoomi et al. [9] from 2006 to 2008 that the laparoscopic approach to appendectomy exceeded that of the open approach. The long interval for the adoption of laparoscopic appendectomy was likely related to the minimally improved benefit of the laparoscopic approach compared with the open approach and the issue of possibly increased intra-abdominal infection after the laparoscopic approach [10,11]. Similarly, the first laparoscopic colectomy was reported in 1991 [12]. In the present study, we found that in 2009, the use of laparoscopic colectomy had finally exceeded that of open colectomy. The primary reason for the delay in adoption was the issue of port-site cancer recurrence. This led to a national moratorium on laparoscopic resection of colorectal cancer in the United States until 2004 when the first large randomized trial comparing laparoscopic and open colectomy revealed no increase in the incidence of port-site recurrence [13]. The outcomes of bariatric surgery have dramatically improved during the past decade. Using the UHC national database, Nguyen et al. [14] reported that the in-hospital mortality decreased from.4% in 2002 to.06% in 2009. In the present study, we found that contemporary mortality for bariatric surgery is similar to that of other commonly performed general surgical operations, such as cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery. Laparoscopic colorectal surgery had the greatest mortality; however, most of these cases are performed in older patients with a greater severity of illness. The present study had several limitations. Unlike clinical data, the UHC database is compiled from discharge abstract data and is limited to the in-hospital stay without outpatient follow-up data. For example, deaths that occur after hospital discharge would not be captured in this database. Therefore, our reported in-hospital mortality rate has probably underestimated the true 30-day mortality. Second, the rate of laparoscopy for cholecystectomy and the volume of cholecystectomy cases found in the present study might have been underestimated, because we were only able to analyze 1992 Cholecystectomy 4 2005 Bariatric Surgery 3 2009 Colectomy 1990 1995 2000 2005 2010 1996 Antireflux surgery 6 2006 Appendectomy 9 Fig. 3. Year when laparoscopic technique surpassed that of open technique for general surgical operations.

20 N. T. Nguyen et al. / Surgery for Obesity and Related Diseases 9 (2013) 15 20 cholecystectomy operations performed on an inpatient basis. Outpatient cholecystectomies were not captured in the UHC database. Third, the reported complications and mortality analyzed in the present study were based on the patient characteristics (Table 2) without risk adjustment. Therefore, the low mortality associated with bariatric surgery, appendectomy, and antireflux surgery must be considered within this context. In addition, use of the V code, which represents cases performed laparoscopically and required conversion to an open procedure, might have underestimated the conversion rate because some of these cases could have been coded as primary open procedures. Finally, the rate of laparoscopic usage also reflects the acute nature of the surgical condition. Therefore, we elected to examine only patients who underwent the 7 general surgical operations on an elective basis, except for appendectomy. Despite these limitations, the major strength of the present study was the large sample size and the availability of laparoscopic and open procedural codes for all 7 general operations. Conclusion Within the context of academic centers and elective, inpatient procedures, bariatric surgery has the greatest use of laparoscopy and the lowest conversion rate to open surgery. The in-hospital mortality of laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: a comparison with mini-lap cholecystectomy. Surg Endosc 1989;3:131 3. [2] Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279 89. [3] Nguyen NT, Hinojosa M, Fayad C, Varela E, Wilson SE. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers. J Am Coll Surg 2007;205:248 55. [4] Kemp JA, Zuckerman RS, Finlayson SR. Trends in adoption of laparoscopic cholecystectomy in rural versus urban hospitals. J Am Coll Surg 2008;206:28 32. [5] Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991;1:138 43. [6] Finlayson SR, Laycock WS, Birkmeyer JD. National trends in utilization and outcomes of antireflux surgery. Surg Endosc 2003;17: 864 7. [7] Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4: 353 7. [8] Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59 64. [9] Masoomi H, Mills S, Dolich MO, et al. Comparison of outcomes of laparoscopic versus open appendectomy in adults: data from the Nationwide Inpatient Sample (NIS), 2006 2008. J Gastrointest Surg 2011;15:2226 311. [10] Long KH, Bannon MP, Zietlow SP, et al. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 2001;129:390 400. [11] Hoehne F, Ozaeta M, Sherman B, Miani P, Taylor E. Laparoscopic versus open appendectomy: is the postoperative infectious complication rate different? Am Surg 2005;71:813 5. [12] Jacobs M, Vereja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc Percutan Tech 1991;1:144 50. [13] Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050 9. [14] Nguyen NT, Nguyen B, Smith B, Reavis KM, Elliott C, Hohmann S. Proposal for a bariatric mortality risk classification system for patients undergoing bariatric surgery. Surg Obes Relat Dis Epub 2011 Dec 22.