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Goal: Accurate prediction of operating room (OR) time is critical for effective utilization of resources, optimal staffing, and reduced costs. Currently, electronic health record (EHR) systems aid OR scheduling by predicting OR time for a specific surgeon and operation. On many occasions, the predicted OR time is subject to manipulation by surgeons during scheduling. We aimed to address the use of the EHR for OR scheduling and the impact of manipulations on OR time accuracy., Methods: Between April and August 2022, a pilot study was performed in our tertiary center where surgeons in multiple surgical specialties were encouraged toward nonmanipulation for predicted OR time during scheduling. The OR time accuracy within 5 months before trial (Group 1) and within the trial period (Group 2) were compared. Accurate cases were defined as cases with total length (wheels-in to wheels-out) within ±30 min or ±20% of the scheduled duration if the scheduled time is ≥ or <150 min, respectively. The study included single and multiple Current Procedural Terminology code procedures, while procedures involving multiple surgical specialties (combo cases) were excluded., Principal Findings: The study included a total of 8,821 operations, 4,243 (Group 1) and 4,578 (Group 2), (p < .001). The percentage of manipulation dropped from 19.8% (Group 1) to 7.6% (Group 2), (p < .001), while scheduling accuracy rose from 41.7% (Group 1) to 47.9% (Group 2), (p = .0001) with a significant reduction of underscheduling percentage (38.7% vs. 31.7%, p = .0001) and without a significant difference in the percentage of overscheduled cases (15% vs. 17%, p = .22). Inaccurate OR hours were reduced by 18% during the trial period (2,383 hr vs. 1,954 hr)., Practical Applications: The utilization of EHR systems for predicting OR time and reducing manipulation by surgeons helps improve OR scheduling accuracy and utilization of OR resources., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Foundation of the American College of Healthcare Executives.)

Objective: The leadership team invited surgical team members to participate in educational sessions that created self and other awareness as well as gathered baseline information about these topics: communication, conflict management, emotional intelligence, and teamwork., Design: Each educational session included an inventory that was completed to help participants understand their own characteristics and the characteristics of their team members. The results from these inventories were aggregated, relationships were identified, and the intervention was evaluated., Setting: A level 1 trauma center, Baylor Scott and White Health, in central Texas; a 636-bed tertiary care main hospital and an affiliated children's hospital., Participants: An open invitation for all surgical team members yielded 551 interprofessional OR team members including anesthesia, attending physicians, nursing, physician assistants, residents, and administration., Results: Surgeons' communication styles were individual focused, while other team members were group focused. The most common conflict management mode for surgical team members on average was avoiding, and the least common was collaborating. Surgeons primarily used competing mode for conflict management, with avoiding coming in a close second. Finally, the 5 dysfunctions of a team inventory revealed low accountability scores, meaning the participants struggled with holding team members accountable., Conclusions: Helping team members understand their own and others' strengths and blind spots will help create opportunity for more purposeful and clear communication. Additionally, this knowledge should improve efficiency and safety in the high-stakes environment of the operating room., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Psychological safety enables the interpersonal risk-taking necessary for providing safer patient care in the operating room (OR). Limited studies look at psychological safety in the OR from the perspectives of each highly specialized team member. Therefore, we investigated each member's perspective on the factors that influence psychological safety in the OR. Interviews were conducted with operative team members of a level 1 trauma center in central Texas. The interviews were transcribed, de-identified, and coded by two investigators independently, and thematic analysis was performed. Responses were collected from 21 participants representing all surgical team roles (attending surgeons, attending anesthesiologists, circulating nurses, nurse anesthetists, scrub techs, and residents). Circulating nurse responses were redacted for confidentiality (n = 1). Six major themes influencing psychological safety in the OR were identified. Psychological safety is essential to better, safer patient care. Establishing a climate of mutual respect and suspended judgment in an OR safe for learning will lay the foundation for achieving psychological safety in the OR. Team exercises in building rapport and mutual understanding are important starting points., (Copyright © 2022 Baylor University Medical Center.)

Background: Surgical site infection (SSI) rates in elective colorectal surgery remain high due to intraoperative exposure of colonic bacteria at the surgical site. We aimed to evaluate 30-day SSI outcomes of a novel wound retractor that combines barrier protection with continuous wound irrigation in elective colorectal resection., Materials and Methods: A retrospective single-center cohort-matched analysis included all patients undergoing elective colorectal resection utilizing the novel irrigating wound protector (IWP) from April 2015 to July 2019. A control cohort of patients who underwent the same procedures with a standard wound protector over the same time period were also identified. Patients from both groups were matched for procedure type, procedure approach, pathology requiring operation, age, sex, race, body mass index, diabetes, smoker status, hypertension, presence of disseminated cancer, current steroid or immunosuppressant use, wound classification, and American Society of Anesthesiologist classification. SSI frequency, SSI subtype (superficial, deep, or organ space), hospital length of stay (LOS) and associated procedure were tabulated through 30 postoperative days. Fisher's exact test and number needed to treat (NNT) were used to compare SSI rates and estimate cost between both groups., Results: The IWP group had 41 patients. The control group had 82 patients. Control-matched variables were similar for both groups. 30-day SSI rates were significantly lower in the IWP group (P=0.0298). length of stay was significantly shorter in the IWP group (P=0.0150). The NNT for the IWP to prevent one episode of SSI was 8.2 patients., Conclusions: The novel IWP device shows promise to reducing the risk of SSI in elective colorectal surgery., (Copyright © 2021. Published by Elsevier Inc.)

Background: The Quality In-Training Initiative (QITI) provides hands-on quality improvement education for residents. As our institution has ranked in the bottom quartile for prolonged mechanical ventilation (PMV) according to the National Surgical Quality Improvement Program (NSQIP), we sought to illustrate how our resident-led QITI could be used to determine perioperative contributors to PMV., Materials and Methods: The Model for Improvement framework (developed by Associates in Process Improvement) was used to target postoperative ventilator management. However, baseline findings from our 2016 NSQIP data suggested that preoperative patient factors were more likely contributing to PMV. Subsequently, a retrospective one-to-one case-control study was developed, comparing preoperative NSQIP risk calculator profiles for PMV patients to case-matched patients for age, sex, procedure, and emergent case status. Chart review determined ventilator time, 30-d outcomes, and all-cause mortality., Results: Forty-five patients with PMV (69% elective) had a median ventilator time of 134 h (interquartile range 87-254). The NSQIP calculator demonstrated increased preoperative risk percentages in PMV patients when compared to case-matched patients for any complication (includes PMV), predicted length of stay, and death (all P < 0.05). Thirty-day outcomes were worse for the PMV group in categories for sepsis, pneumonia, unplanned reoperation, 30-d mortality, rehab facility discharge, and length of stay (all P < 0.05). All-cause mortality was also significantly higher for PMV patients (P < 0.05)., Conclusions: Resident-led QITI projects enhance resident education while exposing opportunities for improving care. Preoperative patient factors play a larger-than-anticipated role in PMV at our institution. Ongoing efforts are aimed toward preoperative identification and optimization of high-risk patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Frailty is an emerging risk factor for surgical outcomes; however, its application across large populations is not well defined. We hypothesized that frailty affects postoperative outcomes in a large health care system., Study Design: Frailty was prospectively measured in elective surgery patients (January 2016 to June 2017) in a health care system (4 hospitals/901 beds). Frailty classifications-low (0), intermediate (1 to 2), high (3 to 5)-were assigned based on the modified Hopkins score. Operations were classified as inpatient (IP) vs outpatient (OP). Outcomes measured (30-day) included major morbidity, discharge location, emergency department (ED) visit, readmission, length of stay (LOS), mortality, and direct-cost/patient., Results: There were 14,530 elective surgery patients (68.1% outpatient, 31.9% inpatient) preoperatively assessed (cardiothoracic 4%, colorectal 4%, general 29%, oral maxillofacial 2%, otolaryngology 8%, plastic surgery 13%, podiatry 6%, surgical oncology 5%, transplant 3%, urology 24%, vascular 2%). High frailty was found in 3.4% of patients (5.3% IP, 2.5% OP). Incidence of major morbidity, readmission, and mortality correlated with frailty classification in all patients (p < 0.05). In the IP cohort, length of stay in days (low 1.6, intermediate 2.3, high 4.1, p < 0.0001) and discharge to facility increased with frailty (p < 0.05). In the OP cohort, ED visits increased with frailty (p < 0.05). Frailty was associated with increased direct-cost in the IP cohort (low, $7,045; intermediate, $7,995; high, $8,599; p < 0.05)., Conclusions: Frailty affects morbidity, mortality, and health care resource use in both IP and OP operations. Additionally, IP cost increased with frailty. The broad applicability of frailty (across surgical specialties) represents an opportunity for risk stratification and patient optimization across a large health care system., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator., Patients and Methods: A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study., Results: A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device., Conclusions: These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.

Background: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. Key to its pathogenesis is the degree of intraoperative bacterial contamination at the surgical site. The purpose of this study was to evaluate a novel wound retractor at reducing bacterial contamination., Methods: A prospective multicenter pilot study utilizing a novel wound retractor combining continuous irrigation and barrier protection was conducted in patients undergoing elective colorectal resections. Culture swabs were collected from the incision edge prior to device placement and from the exposed and protected incision edge prior to device removal. The primary and secondary endpoints were the rate of enteric and overall bacterial contamination on the exposed incision edge as compared to the protected incision edge, respectively. The safety endpoint was the absence of serious device-related adverse events., Results: A total of 86 patients were eligible for analysis. The novel wound retractor was associated with a 66% reduction in overall bacterial contamination at the protected incision edge compared to the exposed incision edge (11.9 vs. 34.5%, P < 0.001), and 71% reduction in enteric bacterial contamination (9.5% vs. 33.3%, P < 0.001). The incisional SSI rate was 2.3% in the primary analysis and 1.2% in those that completed the protocol. There were no adverse events attributed to device use., Conclusions: A novel wound retractor combining continuous irrigation and barrier protection was associated with a significant reduction in bacterial contamination. Improved methods to counteract wound contamination represent a promising strategy for SSI prevention (NCT 02413879).

Background: Length of hospital stay (LOS) is an indirect measure of surgical quality and a surrogate for cost. The impact of postoperative complications on LOS following elective colorectal surgery is not well defined. The purpose of this study is to determine the contribution of specific complications towards LOS in elective laparoscopic colectomy patients., Materials and Methods: American College of Surgeon's National Surgical Quality Improvement Program database (2011-2014) was queried for patients undergoing elective laparoscopic partial colectomy with primary anastomosis. Demographics, specific 30 d postoperative complications and LOS, were evaluated. A negative binomial regression adjusting for demographic variables and complications was performed to explore the impact of individual complications on LOS, significance set at P < 0.05., Results: A total of 42,365 patients were evaluated, with an overall median LOS 4.0 d (interquartile range, 3.0-5.0). Unplanned reoperation and pneumonia each increase LOS by 50%; superficial surgical site infections (SSIs), organ space SSI sepsis, urinary tract infection, ventilation >48 h, pulmonary embolism, and myocardial infarction each increase LOS by at least 25% (P < 0.0001). When accounting for additional LOS and rate of complications, unplanned reoperation, bleeding requiring transfusion within 72 h, and superficial SSIs were the highest impact complications., Conclusions: In laparoscopic colectomy, each complication uniquely impacts LOS, and therefore cost. Utilizing this model, individual hospitals can implement pathways targeting specific complication profiles to improve care and minimize health care cost., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: General surgery training has historically lacked a standardized approach to resident quality improvement (QI) education aside from traditional morbidity and mortality conference. In 2013, the ACGME formalized QI as a component of residency training. Our residency chose the NSQIP Quality In-Training Initiative (QITI) as the foundation for our QI training. We hypothesized that a focused curriculum based on outcomes would produce change in culture and improve the quality of patient care., Study Design: Quality improvement curriculum design and implementation were retrospectively reviewed. Institutional NSQIP data pre-, during, and post-curriculum implementation were reviewed for improvement., Results: A QITI project committee designed a 2-year curriculum, with 3 parts: didactics, focused on methods of data collection, QI processes, and techniques; review of current institutional performance, practice, and complication rates; and QI breakout groups tasked with creating "best practice" guidelines addressing common complications in our NSQIP semi-annual reports. Educational presentations were given to the surgical department addressing reduction of cardiac complications, pneumonia, surgical site infections (SSIs), and urinary tract infections (UTIs). Twenty-four residents completed both years of the QITI curriculum. National NSQIP decile ranks improved in known high outlier areas: cardiac complications, ninth to fourth decile; pneumonia, eighth to first decile; SSIs, tenth to second decile; and UTIs, eighth to third decile. Pneumonia and SSI rates demonstrated statistical improvement after curriculum implementation (p < 0.003)., Conclusions: Implementing a QITI curriculum with a full resident complement is feasible and can positively affect surgical morbidity and nationally benchmarked performance. Resident QI education is essential to future success in delivering high quality surgical care., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To identify patients with a high risk of 30-day mortality after elective surgery, who may benefit from referral for tertiary care, an institution-specific process using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) Risk Calculator was developed. The goal was to develop and validate the methodology. Our hypothesis was that the process could optimize referrals and reduce mortality., Study Design: A VASQIP risk score was calculated for all patients undergoing elective noncardiac surgery at a single Veterans Affairs (VA) facility. After statistical analysis, a VASQIP risk score of 3.3% predicted mortality was selected as the institutional threshold for referral to a tertiary care center. The model predicted that 16% of patients would require referral, and 30-day mortality would be reduced by 73% at the referring institution. The main outcomes measures were the actual vs predicted referrals and mortality rates at the referring and receiving facilities., Results: The validation included 565 patients; 90 (16%) had VASQIP risk scores greater than 3.3% and were identified for referral; 60 consented. In these patients, there were 16 (27%) predicted mortalities, but only 4 actual deaths (p = 0.007) at the receiving institution. When referral was not indicated, the model predicted 4 mortalities (1%), but no actual deaths (p = 0.1241)., Conclusions: These data validate this methodology to identify patients for referral to a higher level of care, reducing mortality at the referring institutions and significantly improving patient outcomes. This methodology can help guide decisions on referrals and optimize patient care. Further application and studies are warranted., (Copyright © 2017 American College of Surgeons. All rights reserved.)

Lower limb ischemia in diabetic patients is a result of macro- and microcirculation dysfunction. Diabetic patients undergoing limb amputation carry high mortality and morbidity rates, and decision making concerning the level of amputation is critical. Aim of this study is to evaluate a novel microdialysis technique to monitor tissue microcirculation preoperatively and predict the success of limb amputation in such patients. Overall, 165 patients with type 2 diabetes mellitus undergoing lower limb amputation were enrolled. A microdialysis catheter was placed preoperatively at the level of the intended flap for the stump reconstruction, and the levels of glucose, glycerol, lactate and pyruvate were measured for 24 consecutive hours. Patients were then amputated and monitored for 30 days regarding the outcome of amputation. Failure of amputation was defined as delayed healing or stump ischemia. Patients were divided into two groups based on the success of amputation. There was no difference between the two groups regarding gender, ASA score, body mass index, comorbidities, diagnostic modality used, level of amputation, as well as glucose, glycerol, and pyruvate levels. However, local concentrations of lactate were significantly different between the two groups and lactate/pyruvate (L/P) ratio was independently associated with failed amputation (threshold defined at 25.35). Elevated preoperative tissue L/P ratio is independently associated with worse outcomes in diabetic patients undergoing limb amputation. Therefore, preoperative tissue L/P ratio could be used as a predicting tool for limb amputation's outcome, although more clinical data are needed to provide safer conclusions., (© 2016 by the Wound Healing Society.)

Background: The purpose of this study was to examine whether incorporating digital and video multimedia components improved surgical time-out performance of a surgical safety checklist., Methods: A prospective pilot study was designed for implementation of a multimedia time-out, including a patient video. Perceptions of the staff participants were surveyed before and after intervention (Likert scale: 1, strongly disagree to 5, strongly agree)., Results: Employee satisfaction was high for both time-out procedures. However, employees appreciated improved clarity of patient identification (P < .05) and operative laterality (P < .05) with the digital method. About 87% of the respondents preferred the digital version to the standard time-out (75% anesthesia, 89% surgeons, 93% nursing). Although the duration of time-outs increased (49 and 79 seconds for standard and digital time-outs, respectively, P > .001), there was significant improvement in performance of key safety elements., Conclusion: The multimedia time-out allows improved participation by the surgical team and is preferred to a standard time-out process., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC)., Methods: A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures., Results: Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045)., Conclusions: Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The American Recovery and Reinvestment Act mandates "meaningful use" of an electronic health record (EHR) to receive current financial incentives and to avoid future financial penalties. Surgeons' ongoing adoption of an EHR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records. We conducted a survey to query surgeons at our institution regarding their perception of the EHR 3 months after institutional implementation. A total of 59 surveys were obtained from 24 senior staff and 35 residents. Results showed that surgeons believed the EHR was more effective as a billing tool than as a form of clinical documentation and believed the billing was more complete and accurate with the EHR. Surgeons also expressed concern that the EHR would negatively impact patient satisfaction, but in spite of this, they indicated that their personal quality of life was not negatively impacted.

Background: The relation between MRSA colonization and empyema culture results is unknown. We hypothesized that MRSA-colonized patients would be more likely to develop MRSA empyema, and sought to determine if MRSA culture positive empyema had an effect on clinical management or patient outcomes., Methods: The medical records of patients with a diagnosis of empyema from 2007-2010 were retrospectively reviewed for demographics, MRSA colonization status, comorbidities, culture results, clinical management, and discharge disposition. The relationship between MRSA colonization status and culture results was analyzed by bivariate testing. Logistic regression was utilized to determine relations between empyema culture results, comorbidities, and clinical course., Results: Of 147 patients identified with empyema, 16 (10.8%) were MRSA colonized. Colonized patients had substantially higher rates of MRSA-positive empyema cultures (75% vs. 4.6%; p<0.001). A greater percentage of the MRSA-positive empyema patients 66.7% were managed with tube thoracostomy alone, compared with culture positive patients with an organism other than MRSA and those with negative cultures (39% and 34% respectively; p=0.043). Neither empyema culture results nor colonization status were substantial risk factors for poor discharge (skilled nursing facility, long-term care hospital, or death)., Conclusions: MRSA-colonized patients hospitalized with empyema are highly likely to have cultures positive for MRSA.

Background: Increased focus on reducing patient harm has led to surgical safety initiatives, including time-out, surgical safety checklists, and debriefings. The perception of the lay public of the surgical safety process is largely unknown., Methods: A 20-question survey focused on perceptions of surgical safety practice was distributed to a random sample of patients following elective operations requiring hospitalization. Responses were measured by a 7-point Likert scale. Qualitative feedback was obtained through nonphysician-moderated sessions. Participation was voluntary and anonymous., Results: Surveys were distributed to 345 patients of whom 102 (29.5%) responded. Overall, patients felt safe as evidenced by scores for the questions "I felt safe the day of my surgery" (6.53 ± 0.72) and "Mistakes rarely happen during surgery" (5.39 ± 1.51). Patients undergoing their first surgery and patients with higher income levels were associated with a significant decrease in specific safety perceptions. Qualitative feedback sessions identified the physician-patient relationship as the most important factor positively influencing patient safety perceptions., Conclusion: Current surgical safety practice is perceived positively by our patients; however, patients still identify physician-patient interactions, relationships, and trust as the most positive factors influencing their perception of the safety environment.

Background: Case mix index (CMI) is calculated to determine the relative value assigned to a Diagnosis-Related Group. Accurate documentation of patient complications and comorbidities and major complications and comorbidities changes CMI and can affect hospital reimbursement and future pay for performance metrics., Study Design: Starting in 2010, a physician panel concurrently reviewed the documentation of the trauma/acute care surgeons. Clarifications of the Centers for Medicare and Medicaid Services term-specific documentation were made by the panel, and the surgeon could incorporate or decline the clinical queries. A retrospective review of trauma/acute care inpatients was performed. The mean severity of illness, risk of mortality, and CMI from 2009 were compared with the 3 subsequent years. Mean length of stay and mean Injury Severity Score by year were listed as measures of patient acuity. Statistical analysis was performed using ANOVA and t-test, with p < 0.05 for significance., Results: Each year demonstrated an increase in severity of illness, risk of mortality, and CMI compared with baseline values (p < 0.05). Length of stay was not significantly different, reflecting similar patient populations throughout the study. Injury Severity Score decreased in 2011 and 2012 compared with 2009, reflecting a lower level of injury in the trauma population., Conclusions: A concurrent documentation review significantly increases severity of illness, risk of mortality, and CMI scores in a trauma/acute care service compared with pre-program levels. These changes reflect more accurate key word documentation rather than a change in patient acuity. The increased scores might impact hospital reimbursement and more accurately stratify outcomes measures for care providers., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Health care is evolving into a value-based reimbursement system focused on quality and outcomes. Reported outcomes from national databases are used for quality improvement projects and public reporting. This study compared reported outcomes in cardiac and thoracic surgery from two validated reporting databases-the Society of Thoracic Surgeons (STS) database and the National Surgical Quality Improvement Program (NSQIP)-from January 2011 to June 2012. Quality metrics and outcomes included mortality, wound infection, prolonged ventilation, pneumonia, renal failure, stroke, and cardiac arrest. Comparison was made by chi-square analysis. A total of 737 and 177 cardiac surgery cases and 451 and 105 thoracic surgery cases were captured by the STS database and NSQIP, respectively. Within cardiac surgery, there was a statistically significant difference in the reported rates of prolonged ventilation, renal failure, and mortality. No significant differences were found for the thoracic surgery data. In conclusion, our data indicated a significant discordance in quality reporting for cardiac surgery between the NSQIP and the STS databases. The disparity between databases and duplicate participation strongly indicates that a unified national quality reporting program is required. Consolidation of reporting databases and standardization of morbidity definitions across all databases may improve participation and reduce hospital cost.

Background: The Surgical Safety Checklist (SSC) improves patient safety and outcomes; however, barriers to effective use include the perceived negative impact on operating room (OR) efficiency. The purpose of this study was to determine the effect of SSC implementation on OR efficiency., Methods: All operations at our large multispecialty tertiary care hospital were reviewed for 1-year pre- and 1-year post-SSC implementation. OR efficiency included operating room time, operation time, first starts on time, same-day cancellations, and OR disposable cost., Results: A total of 35,570 operations were reviewed: 17,204 pre-SSC and 18,366 post-SSC. There was no difference between groups for operating room time (P = .93), operation time (P = .66), first starts on time (P = .15), and same-day cancellations (P = .57). The mean OR disposable cost was significantly lower ($70/operation) for the post-SSC group (P < .01)., Conclusions: The implementation of an SSC does not negatively impact OR efficiency and should not be considered a barrier to effective use. Our data suggest that SSC use can reduce overall cost per surgical procedure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The Surgical Safety Checklist (SSC) has been introduced as an effective tool for reducing perioperative mortality and complications. Although reported completion rates are high, objective compliance is not well defined. The purpose of this retrospective analysis is to determine SSC compliance as measured by accuracy and completion, and factors that can affect compliance., Study Design: In September 2010, our institution implemented an adaptation of the World Health Organization's SSC in an effort to improve patient safety and outcomes. A tool was developed for objective evaluation of overall compliance (maximum score 40) that was an aggregate score of completion and accuracy (20 each). Random samples of SSCs were analyzed at specific, predefined, time points throughout the first year after implementation. Procedure start time, operative time, and case complexity were assessed to determine association with compliance., Results: A total of 671 SSCs were analyzed. The participation rate improved from 33% (95 of 285) at week 1 to 94% (249 of 265) at 1 year (p < 0.0001, chi-square test). Mean overall compliance score was 27.7 (± 5.4 SD) of 40 possible points (69.3% ± 13.5% of total possible score; n = 671) and did not change over time. Although completion scores were high (16.9 ± 2.7 out of 20 [84.5% ± 13.6%]), accuracy was poor (10.8 ± 3.4 out of 20 [54.1% ± 16.9%]). Overall compliance score was significantly associated with case start-time (p < 0.05), and operative time and case complexity showed no association., Conclusions: Our data indicate that although implementation of an SSC results in a high level of overall participation and completion, accuracy remained poor. Identification of barriers to effective use is needed, as improper checklist use can adversely affect patient safety., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The World Health Organization Surgical Safety Checklist (SSC) has been shown to decrease surgical site infections (SSI). The Surgical Care Improvement Project (SCIP) SSI reduction bundle (SCIP Inf) contains elements to improve SSI rates. We wanted to determine if integration of SCIP measures within our SSC would improve SCIP performance and patient outcomes for SSI., Methods: An integrated SSC that included perioperative SCIP Inf measures (antibiotic selection, antibiotic timing, and temperature management) was implemented. We compared SCIP Inf compliance and patient outcomes for 1-y before and 1-y after SSC implementation. Outcomes included number of patients with initial post-anesthesia care unit temperature <98.6°F and SSI rates according to our National Surgical Quality Improvement Program data., Results: Implementation of a SCIP integrated SSC resulted in a significant improvement in antibiotic infusion timing (92.7% [670/723] versus 95.4% [557/584]; P < 0.05), antibiotic selection (96.2% [707/735] versus 98.7% [584/592]; P < 0.01), and temperature management (93.8% [723/771] versus 97.7% [693/709]; P < 0.001). Furthermore, we found a significant reduction in number of patients with initial post-anesthesia care unit temperature <98.6°F from 9.7% (982/10,126) to 6.9% (671/9676) (P < 0.001). Institutional SSI rates decreased from 3.13% (104/3319) to 2.96% (107/3616), but was not significant (P = 0.72). SSI rates according to specialty service were similar for all groups except colorectal surgery (24.1% [19/79] versus 11.5% [12/104]; P < 0.05)., Conclusion: Implementation of an integrated SSC can improve compliance of SSI reduction strategies such as SCIP Inf performance and maintenance of normothermia. This did not, however, correlate with an improvement in overall SSI at our institution. Further investigation is required to determine other factors that may influence SSI at an institutional level., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Residents and fellows perform a large portion of the hands-on patient care in tertiary referral centers. As frontline providers, they are well suited to identify quality and patient safety issues. As payment reform shifts hospitals to a fee-for-value-type system with reimbursement contingent on quality outcomes, preventive health, and patient satisfaction, house staff must be intimately involved in identifying and solving care delivery problems related to quality, outcomes, and patient safety. Many challenges exist in integrating house staff into the quality improvement infrastructure; these challenges may ideally be managed by the development of a house staff quality council (HSQC)., Methods: Residents and fellows at Scott & White Memorial Hospital interested in participating in a quality council submitted an application, curriculum vitae, and letter of support from their program director. Twelve residents and fellows were selected based on their prior quality improvement experience and/or their interest in quality and safety initiatives., Results: In only 1 year, our HSQC, an Alliance of Independent Academic Medical Centers National Initiative III project, initiated 3 quality projects and began development of a fourth project., Conclusion: Academic medical centers should consider establishing HSQCs to align institutional quality goals with residency training and medical education.

Background: Surgical safety programs have been shown to reduce patient harm; however, there is variable compliance. The purpose of this study is to determine if innovative technology such as Quick Response (QR) codes can facilitate surgical safety initiatives., Methods: We prospectively evaluated the use of QR codes during the surgical time-out for 40 operations. Feasibility and accuracy were assessed. Perceptions of the current time-out process and the QR code application were evaluated through surveys using a 5-point Likert scale and binomial yes or no questions., Results: At baseline (n = 53), survey results from the surgical team agreed or strongly agreed that the current time-out process was efficient (64%), easy to use (77%), and provided clear information (89%). However, 65% of surgeons felt that process improvements were needed. Thirty-seven of 40 (92.5%) QR codes scanned successfully, of which 100% were accurate. Three scan failures resulted from excessive curvature or wrinkling of the QR code label on the body. Follow-up survey results (n = 33) showed that the surgical team agreed or strongly agreed that the QR program was clearer (70%), easier to use (57%), and more accurate (84%). Seventy-four percent preferred the QR system to the current time-out process., Conclusions: QR codes accurately transmit patient information during the time-out procedure and are preferred to the current process by surgical team members. The novel application of this technology may improve compliance, accuracy, and outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The World Health Organization (WHO) surgical safety checklist has been shown to decrease mortality and complications and has been adopted worldwide. However, system flaws and human errors persist. Identifying provider perspectives of patient safety initiatives may identify strategies for improvement. The purpose of this study was to determine provider perspectives of surgical safety checklist implementation in an effort to improve initiatives that enhance surgical patients' safety., Methods: In September 2010, a WHO-adapted surgical safety checklist was implemented at our institution. Surgical teams were invited to complete a checklist-focused questionnaire 1 month before and 1 year after implementation. Baseline and follow-up results were compared., Results: A total of 437 surgical care providers responded to the survey: 45% of providers responded at baseline and 64% of providers responded at follow-up. Of the total respondents, 153 (35%) were nurses, 104 (24%) were anesthesia providers, and 180 (41%) were surgeons. Overall, we found an improvement in the awareness of patient safety and quality of care, with significant improvements in the perception of the value of and participation in the time-out process, in surgical team communication, and in the establishment and clarity of patient care needs. Some discordance was noted between surgeons and other surgical team members, indicating that barriers in communication still exist. Overall, approximately 65% of respondents perceived that the checklist improved patient safety and patient care; however, we found a strong negative perception of operating room efficiency., Conclusion: Implementation of a surgical safety checklist improves perceptions of surgical safety. Barriers to implementation exist, but staff feedback may be used to enhance the sustainability and success of patient safety initiatives.

Background: It has been shown in many solid tumors that the overexpression of the pro-survival Bcl-2 family members Bcl-2/Bcl-xL and Mcl-1 confers resistance to a variety of chemotherapeutic agents. We designed the BH3 α-helix mimetic JY-1-106 to engage the hydrophobic BH3-binding grooves on the surfaces of both Bcl-xL and Mcl-1., Methods: JY-1-106-protein complexes were studied using molecular dynamics (MD) simulations and the SILCS methodology. We have evaluated the in vitro effects of JY-1-106 by using a fluorescence polarization (FP) assay, an XTT assay, apoptosis assays, and immunoprecipitation and western-blot assays. A preclinical human cancer xenograft model was used to test the efficacy of JY-1-106 in vivo., Results: MD and SILCS simulations of the JY-1-106-protein complexes indicated the importance of the aliphatic side chains of JY-1-106 to binding and successfully predicted the improved affinity of the ligand for Bcl-xL over Mcl-1. Ligand binding affinities were measured via an FP assay using a fluorescently labeled Bak-BH3 peptide in vitro. Apoptosis induction via JY-1-106 was evidenced by TUNEL assay and PARP cleavage as well as by Bax-Bax dimerization. Release of multi-domain Bak from its inhibitory binding to Bcl-2/Bcl-xL and Mcl-1 using JY-1-106 was detected via immunoprecipitation (IP) western blotting.At the cellular level, we compared the growth proliferation IC50s of JY-1-106 and ABT-737 in multiple cancer cell lines with various Bcl-xL and Mcl-1 expression levels. JY-1-106 effectively induced cell death regardless of the Mcl-1 expression level in ABT-737 resistant solid tumor cells, whilst toxicity toward normal human endothelial cells was limited. Furthermore, synergistic effects were observed in A549 cells using a combination of JY-1-106 and multiple chemotherapeutic agents. We also observed that JY-1-106 was a very effective agent in inducing apoptosis in metabolically stressed tumors. Finally, JY-1-106 was evaluated in a tumor-bearing nude mouse model, and was found to effectively repress tumor growth. Strong TUNEL signals in the tumor cells demonstrated the effectiveness of JY-1-106 in this animal model. No significant side effects were observed in mouse organs after multiple injections., Conclusions: Taken together, these observations demonstrate that JY-1-106 is an effective pan-Bcl-2 inhibitor with very promising clinical potential.

Background: Single-incision laparoscopic (SIL) colectomy has gained significant momentum with anticipated benefit of improved cosmesis. Feasibility and safety of SIL colectomy have been shown; however, benefits are not well defined. The purpose of this study is to directly compare outcomes of SIL sigmoid colectomy for diverticular disease with standard multiport laparoscopic (LAP) technique., Methods: SIL sigmoid colectomy cases performed for diverticular disease between August 2009 and July 2011 were case matched for age, gender, body mass index, American Society of Anesthesiologists score, previous abdominal operation, and need to mobilize the splenic flexure and compared with an equal number of LAP cases. Data analyzed included operative time, estimated blood loss, procedure conversion, incision length, length of hospital stay (LOS), 30-d hospital readmission, and postoperative pain scores., Results: Twenty patients were analyzed in each group with no significant differences found in the six case-matching criteria. Operative time, conversions, estimated blood loss, surgical site infection, and hospital readmissions were similar. The mean incision length for both groups was 5cm (P=0.72). LOS was 3.7d for the SIL group, which was >1d shorter than that for the LAP group (5.0d; P<0.05). Pain score at post-anesthesia care unit discharge and total amount of narcotic pain medication delivered in the post-anesthesia care unit was significantly less in the SIL group (P<0.05), as was maximum visual analog scale pain score on postoperative day 1 and postoperative day 2 (P≤0.01)., Conclusions: SIL sigmoid colectomy is associated with noncosmetic benefits, including a reduction in early postoperative pain and decreased LOS. These findings may be related to reduced abdominal wall trauma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to determine whether methicillin-resistant Staphylococcus aureus (MRSA) colonization affects surgical site infections (SSI) after major gastrointestinal (GI) operations., Methods: We retrospectively reviewed the charts of all patients undergoing major GI surgery from December 2007 to August 2009. All patients were tested for MRSA colonization and grouped according to results (MRSA+, methicillin-sensitive S. aureus [MSSA]+, and negative). Data analyzed included demographics, incidence of SSI, and wound culture results., Results: A total of 1,137 patients were identified; 78.9 % negative, 14.7 % MSSA+, and 6.4 % MRSA+. The mean age was 59.5 years, 44.5 % of the patients were men, and 47.9 % of the patients underwent colorectal operation. SSI was identified in 101 (8.9 %) patients and was higher in the MRSA+ group than the negative and MSSA+ groups (13.7 vs. 9.4 vs. 4.2 %; p < 0.05). Although MRSA colonization had an odds ratio of 1.43 for developing an SSI, it was not a significant independent risk factor. However, the MRSA+ group was strongly associated with MRSA cultured from the wound when SSI was present (70 vs. 8.5 %; p < 0.0001)., Conclusions: MRSA colonization is not an independent risk factor for SSI following major GI operations; however, it is strongly predictive of MRSA-associated SSI in these patients. Preoperative MRSA nasal swab test with decolonization may reduce the incidence of MRSA-associated SSI after major GI surgery.

Background: Full thickness rectal prolapse (FTRP) is managed with an abdominal or perineal operation. Traditionally, the approach has been determined by patient age and comorbidities. Our aim was to determine operative trends and outcomes for repair of FTRP in elderly patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database., Study Design: We queried the ACS NSQIP database from 2006 to 2009 for patients with FTRP who were 70 years of age or older. Patients were grouped according to type of surgical repair: laparoscopic (LR), open (OR), or perineal (PR) technique. We reviewed demographics, operative trends of surgical technique, and short-term outcomes for each group., Results: A total of 816 patients were analyzed; 596 (73%) PR, 130 (16%) OR, and 90 (11%) LR patients. Patients who received OR and LR had lower mean American Society of Anesthesiologists (ASA) scores than PR patients (2.6, 2.5, and 2.7, respectively, p < 0.001). The percentage of LR and OR procedures decreased as age increased by decade; the inverse was seen for PR (p < 0.001). The distribution of operative techniques has not changed from year to year. Length of stay was significantly shorter for LR (3.77 days) and PR (3.44 days) patients vs OR patients (6.23 days) (p = 0.01). Complication rates were 2.22%, 8.72%, and 12.31% for LR, PR, and OR, respectively (p = 0.021). Open surgery was the only factor associated with an increased complication rate, with an odds ratio of 6.29 (95% CI 1.38 to 28.6, p < 0.02)., Conclusions: Despite the appeal of perineal proctectomy in the elderly and debilitated patient, the approach to FTRP is slowly evolving in the era of laparoscopic surgery. Laparoscopic repair of FTRP in the elderly is associated with improved short-term outcomes when compared with OR and PR., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Laparoscopic colorectal surgery has advantages over open surgery including shorter postoperative length of hospital stay, early return of bowel function, decreased complications and reduced postoperative pain. Innovative minimally invasive surgery techniques such as single-incision laparoscopic surgery (SIL) have emerged to further enhance outcomes of conventional laparoscopy. This technique uses a single small incision for access of all instruments and specimen extraction. This concept has been proposed to improve cosmesis and enhance recovery. Technological advances have been introduced to overcome the challenges of co-axial instrument movement and collision that is inherent to SIL surgery. The application of SIL techniques to colorectal surgery is in its infancy, but gaining significant momentum. Early case reports and series have shown feasibility and safety. Emerging comparative studies of SIL colectomy to standard laparoscopic techniques are providing evidence of equivalency with potential benefit in outcomes such as reduced early postoperative pain and shortened length of hospital stay. The application of the SIL platform to robotics and transanal surgery demonstrates the broadening scope of this innovative field. However, we must be cognizant of the impact on surgeon training and resident education. In this review we present the current evidence supporting the application of SIL to colorectal surgery.

Objective: The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons., Background: Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported., Methods: Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores., Results: Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions., Conclusions: SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.

Purpose: To compare single-incision laparoscopic (SIL) with multiport laparoscopic (LAP) colectomy in patients with colon cancer to assess oncologic resection and 1-year outcomes., Methods: We compared patients who underwent SIL colectomy for colon cancer with an equal number of case-matched LAP colectomy patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, previous abdominal operations, and operation type. Results of oncologic resection included lymph node (LN) yield and margins. One-year outcomes included cancer recurrence and death., Results: Twenty-six patients were identified for SIL and LAP colectomy groups with no differences in case matching (age, P = .70; gender, P > .99; BMI, P = .74; ASA score, P > .99; previous abdominal operation, P > .99; and operation-type, P > .99). Oncologic resection was similar for both groups. Mean LN yield was 17 (P = .88). There were no positive margins and 2 (8%) patients had proximal/distal margin of <5 cm in each group. The mean follow-up was 13 and 21 months for the SIL and LAP groups, respectively (P < .001), with 2(8%) recurrences in each group, and no port-site recurrences or deaths. Disease-free survival at 1 year was 92% for both groups., Conclusion: These data suggest that SIL colectomy for cancer provides equivalent oncologic resection and 1-year outcomes compared with a standard LAP technique. Further studies are required to determine long-term oncologic outcomes, including recurrence and survival rates., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Single-incision laparoscopic (SIL) colectomy is an advance in minimally invasive colorectal surgical techniques. Feasibility and safety of SIL colectomy has been reported; however, benefits and outcomes are not well-defined. The purpose of this study was to compare outcomes of SIL right colectomy with multiport laparoscopic (LAP) and hand-assisted laparoscopic (HAL) techniques., Methods: SIL right colectomy cases performed between August 2009 and April 2010 were case-matched for age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, and pathology to an equivalent number of LAP and HAL right colectomy cases. Data analyzed included operative time, procedure conversion, incision length, length of hospital stay, 30-day hospital readmission, surgical site infection and maximum postoperative pain score., Results: Twenty-nine patients were analyzed in each of 3 groups (SIL, LAP, and HAL). The mean age (p = 0.96), body mass index (p = 0.48), American Society of Anesthesiologists score (p = 0.74), and rate of previous abdominal operation (p = 0.95) were similar, and sex and pathology were identical among groups. Operative time and conversion rates were similar. The incision length for SIL (4.5 cm) and LAP (5.1 cm) groups was similar, and both were significantly shorter than HAL group (7.2 cm; p < 0.001). Length of hospital stay was 3.4 days for the SIL group and was more than 1-day shorter than LAP and HAL groups (p < 0.05). Postoperative surgical site infection and hospital readmission were similar among groups. Maximum pain score on postoperative days 1 and 2 was significantly lower in SIL group (p < 0.05)., Conclusions: SIL right colectomy can improve patient recovery through a decrease in early postoperative pain and shorter length of hospital stay when compared with established laparoscopic techniques., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Minimally invasive adrenalectomy is the preferred surgical approach for small, benign adrenal neoplasms. Posterior retroperitoneoscopic adrenalectomy is associated with potential surgical advantages. We sought to investigate the feasibility and early outcomes for robot-assisted posterior adrenalectomy, which has not been previously reported., Patients and Methods: Patients were selected for adrenalectomy based on standard clinical indications. The study was conducted under a protocol approved by the Institutional Review Board. Patients with adrenal masses larger than 7.0 cm, or with a body mass index (BMI) greater than 40, were excluded. Patient demographics, clinical and pathologic data, operative times, and patient outcomes were collected prospectively., Results: Six consecutive patients underwent robot-assisted posterior retroperitoneoscopic adrenalectomy (RAPRA) between June 23, 2009 and January 21, 2010. Five women and one man, ages 45 to 75 years (mean 55.5 years), with a mean BMI of 30, were included. There were three right adrenal tumors and three left adrenal tumors. Mean operative time was 121 minutes with a mean robot time of 57 minutes for the five patients in whom the entire adrenal dissection was performed robotically. There was essentially no morbidity and no mortality., Conclusion: This study represents the first report of RAPRA, and demonstrates the feasibility of performing this procedure with good patient outcomes.

Purpose: We sought to compare the effectiveness of a novel antibiotic irrigation device to the standard O-ring wound retractor in preventing surgical site infections (SSIs) following colorectal resections., Methods: This single-arm clinical trial included patients undergoing colorectal resections utilizing the novel device. A retrospective cohort of patients undergoing the same procedures with the O-ring retractor was selected as the control group. The primary outcome assessed was SSI. Secondary outcomes assessed were overall complications, hospital length of stay (LOS), and 30-day readmission. A univariable and multivariable logistic regression model was built to evaluate the association between SSI as the outcome variable and the use of the novel device as the main independent variable. The model was adjusted for any confounding variables., Results: Eighty-six novel device cases and 170 O-ring retractor cases were enrolled. There were no significant differences between the two groups in terms of demographics and preoperative comorbidities. Cases with the novel device had fewer Pfannenstiel incisions (1.2% vs. 14.6%, p < 0.001). There were no other significant differences in intraoperative variables. SSI rates were significantly lower in the novel device group (1.2% vs. 9.1%, p = 0.014). There were no other significant differences in postoperative complications. Multivariable logistic regression with backward elimination showed that the use of the novel device was significantly more effective against SSI by 92.5% compared to the use of the O-ring retractor., Conclusion: The novel device may contribute to lower SSI rates compared to the O-ring retractor following colorectal resection., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Since the da Vinci SP (dVSP) surgical system was introduced, single-incision robotic surgery (SIRS) for colorectal diseases has gained increasing acceptance. Comparison of the short-term outcomes between SIRS using dVSP and those of conventional multiport laparoscopic surgery (CMLS) was performed to verify its efficacy and safety in colon cancer. The medical records of 237 patients who underwent curative resection for colon cancer by a single surgeon were retrospectively reviewed. Patients were divided into two groups according to surgical modality: SIRS (RS group) and CMLS (LS group). Intra- and postoperative outcomes were analyzed. Of the 237 patients, 140 were included in the analysis. Patients in the RS group (n = 43) were predominantly female, younger, and had better general performance than those in the LS group (n = 97). The total operation time was longer in the RS group than in the LS group (232.8 ± 46.0 vs. 204.1 ± 41.7 min, P < 0.001). The RS group showed faster first flatus passing (2.5 ± 0.9 vs. 3.1 ± 1.2 days, P = 0.003) and less opioid analgesic requirement (analgesic withdrawal within 3 postoperative days: 37.2% vs. 18.6%, P = 0.018) than the LS group. The RS group showed a higher immediate postoperative albumin level (3.9 ± 0.3 vs. 3.6 ± 0.4 g/dL, P < 0.001) and lower C-reactive protein level (6.6 ± 5.2 vs. 9.3 ± 5.5 mg/dL, P = 0.007) than the LS group during the postoperative period. On multivariate analysis after adjusting for deviated patient characteristics, no significant difference was observed in short-term outcomes, except for operation time. SIRS with dVSP showed short-term outcomes comparable with those of CMLS for colon cancer., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients., (© 2023. The Author(s).)

The benign serrated architecture of the hyperplastic polyp has now been recognized in morphologically similar lesions with potential for transformation to colorectal carcinoma: the sessile serrated adenoma (SSA), traditional serrated adenoma (TSA), and mixed polyp. These represent a group of serrated polyps with potential to evolve into colorectal cancer through a different molecular pathway than the traditional adenoma-carcinoma sequence, called the serrated pathway. Genetic characteristics involve a defect in apoptosis caused by BRAF and K-ras mutations that create distinct histologic characteristics of atypia in serrated architectural distortion of the crypts. An evidence-based algorithm for the clinical management of this polyp has yet to be determined. Current recommendations suggest these lesions be managed similar to conventional adenomas. The histology of serrated polyps is reviewed, as well as the common characteristics, and implications for treatment and surveillance.

In the United States, the prevalence of adenomatous polyps found during colonoscopic evaluation ranges from 25 to 41%, and of these, 2 to 5% contain invasive malignancy. The management of the malignant polyp continues to be challenging. Endoscopic resection by polypectomy has been shown to be sufficient for management of certain polyps containing cancer; however, it is important to keep in mind that polypectomy does not remove the lymph node drainage basin and may be an inadequate resection for some adenocarcinoma containing polyps that have specific histologic features. Depth of invasion has been shown to correlate with the risk of lymph node metastasis. Other unfavorable histologic features include lymphovascular invasion, poor differentiation, inability to assess margin (piecemeal resection), and positive resection margin (< 2 mm); these are important factors to consider in management. For these patients formal oncologic surgical resection is indicated. Traditional open or laparoscopic procedures are routinely used for colectomy in these patients. Following polypectomy or segmental colectomy, surveillance of these patients is critical, and can lead to excellent long-term outcomes.

Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuum-assisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.

Background: Isolated perineal endometrioma is a rare entity and often causes diagnostic uncertainty., Cases: Three premenopausal women, none with a prior history of endometriosis, presented with vague perineal pain 3-6 months following obstetric delivery with episiotomy. The latency periods between the onset of symptoms and definitive diagnosis were 3 months, 18 months and 3 years despite multiple physician evaluations in the interim. Patient presentation and management were virtually identical in all cases. Detailed questioning revealed that the pain was located adjacent to the episiotomy incision and waxed and waned with menses. Physical examination revealed a vague fullness adjacent to the episiotomy incision. Endoanal ultrasound revealed a mass of mixed echogenicity adjacent to the external anal sphincter. Transperineal exploration revealed a tumor with the gross appearance of an endometrioma, which was confirmed histologically. Excision of the mass with preservation of the anal sphincter muscle resulted in resolution of symptoms in all patients without the need for hormonal manipulation. No patient suffered diminution of fecal continence., Conclusion: Occult perineal endometriosis should be considered when a woman presents with cyclic pain in the perineum following delivery and episiotomy. Endoanal ultrasound can assist with the diagnosis. Transperineal excision with sparing of the anal sphincter can be curative, without compromising continence.