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IMPORTANCE: Programs that analyze and report rates of surgical complications are an increasing focus of quality improvement efforts. The most comprehensive tool currently used or outcomes monitoring in the United States is the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). OBJECTIVE To compare surgical outcomes experienced by patients treated at hospitals that did vs did not participate in the NSQIP. DESIGN, SETTING, AND PARTICIPANTS: Data from the University HealthSystem Consortium from January 2009 to July 2013 were used to identify elective hospitalizations representing a broad spectrum of elective general/vascular operations in the United States. Data on hospital participation in the NSQIP were obtained through review of semiannual reports published by the ACS. Hospitalizations at any hospital that discontinued or initiated participation in the NSQIP during the study period were excluded after the date on which that hospital's status changed. A difference-in-differences approach was used to model the association between hospital-based participation in NSQIP and changes in rates of postoperative outcomes over time. EXPOSURE: Hospital participation in the NSQIP. MAIN OUTCOMES AND MEASURES: Risk-adjusted rates of any complications, serious complications, and mortality during a hospitalization for elective general/vascular surgery. RESULTS: The cohort included 345 357 hospitalizations occurring in 113 different academic hospitals; 172 882 (50.1%) hospitalizations were in NSQIP hospitals. Hospitalized patients were predominantly female (61.5%), with a mean age of 55.7 years. The types of procedures performed most commonly in the analyzed hospitalizations were hernia repairs (15.7%), bariatric (10.5%), mastectomy (9.7%), and cholecystectomy (9.0%). After accounting for patient risk, procedure type, underlying hospital performance, and temporal trends, the difference-in-differences model demonstrated no statistically significant differences over time between NSQIP and non-NSQIP hospitals in terms of likelihood of complications (adjusted odds ratio, 1.00; 95% Cl, 0.97-1.03), serious complications (adjusted odds ratio, 0.98; 95% Cl, 0.94-1.03), or mortality (adjusted odds ratio, 1.04; 95% Cl, 0.94-1.14). CONCLUSIONS AND RELEVANCE: No association was found between hospital-based participation in the NSQIP and improvements in postoperative outcomes over time within a large cohort of patients undergoing elective general/vascular operations at academic hospitals in the United States. These findings suggest that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement. [ABSTRACT FROM AUTHOR]

Objective: To determine how many cases are required to achieve technical proficiency for hand-assisted laparoscopic surgery (HALS). Design: Retrospective study. Setting: Tertiary care hospital. Patients: Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases. Interventions: Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the "learning period" and "skilled period." Main Outcome Measures: Operative time; shortterm outcomes. Results: The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P<.001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P=.003); left colectomy, 63 minutes (P=.006); sigmoid colectomy, 63 minutes (P<.001); anterior resection, 70 minutes (P<.001); coloanal anastomosis, 52 minutes (P=.003); subtotal colectomy, 75 minutes (P<.001); and total proctocolectomy with ileal reservoir, 80 minutes (P<.001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P<.05) lower during the skilled period. Conclusions: For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons. [ABSTRACT FROM AUTHOR]

Background: Diverting loop ileostomy is used to mitigate the sequelae of anastomotic dehiscence. Objective: To report the rate of complications after ileostomy reversal using standardized definitions to aid physicians who are deciding whether to divert anastomoses. Methods: Patients who underwent diverting loop ileostomy closure from January 1, 2005, through February 28, 2010, were identified using a prospective database. Perioperative variables and 30-day outcomes were reviewed. Complications were graded according to the Clavien- Dindo Classification, in which grade III, IV, or V represents major complications. Univariate analysis assessed the relationship between operative variables and surgical outcomes. Results:Atotal of 944 patients underwent reversal: 43.1% were women, the mean age was 47.2 years, the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 25.7, and 18.5% were American Society of Anesthesiologists class III or IV. Indications for the initial operation were ulcerative colitis (49.5%), rectal cancer (27.5%), diverticular disease (6.8%), and other (16.1%). Anastomotic technique for reversal was sutured fold-over in 466 patients (49.4%), stapled in 315 (33.4%), and handsewn end to end in 163 (17.3%). After reversal, the mean time to first bowel movement, tolerance of soft diet, and discharge from hospital was 2.6, 3.7, and 5.2 days, respectively. Handsewn cases had longer operative times and longer times to bowel movement, soft diet, and discharge. Overall, complications occurred in 203 patients (21.5%), including 45 patients (4.8%) who experienced a major complication; there were no deaths within 30 days. Conclusion: Ileostomy closure is associated with a low rate of major grade III and IV complications and should be reserved for patients who have a predicted postoperative major complication rate of 5% or more without diversion. [ABSTRACT FROM AUTHOR]

Hypothesis: Describe the incidence, type, and detection method of surgical listing errors and implement a system to reduce errors. Design: All errors/discrepancies between the surgical listing and the performed procedure reported to an institutional event line during 2008 were analyzed. Setting: Academic tertiary medical center. Main Outcome Measures: Error characteristics and detection mode were documented. An error causal tree analysis was developed and used to modify the standard listing process to reduce errors. Results: During 2008, 759 listing errors were reported of 55 197 surgical procedures for an error rate of 1.38%. No wrong-site surgeries occurred. The errors were missing laterality (501; 66%), incorrect side (108; 14%), incorrect listing besides laterality (86; 11%), and other (64; 9%). Identification/ correction of the listing error occurred in the following areas: nursing review the evening prior to surgery (517; 68%), preoperative admission unit (132; 17%), operating room (98; 12%), recovery room (6; 0.8%), and other (6; 0.8%). Using a causal tree analysis, error-proofing strategies applied in an electronic standardized case listing system significantly reduced the error rate from 1.50% to 0.54% (P<.05) and 2.06% to 0.49% (P<.05) in gynecologic and colorectal surgery, respectively. Conclusions: Surgical listings errors occur with a low constant rate across specialties. The majorities of errors were related to laterality and were detected prior to surgery. An electronic listing system using standardized case descriptions with required laterality significantly reduced the error frequency. [ABSTRACT FROM AUTHOR]

Objectives: To define risk factors for recurrence and to determine whether postoperative prophylaxis would influence time to recurrence after primary laparoscopic ileocolectomy for Crohn disease. Design: Retrospective record review. Setting: Tertiary academic medical center. Patients: All patients who underwent primary laparoscopic ileocolectomy for terminal ileal Crohn disease between April 28, 1994, and August 3, 2006, at the Mayo Clinic, Rochester, Minnesota. Main Outcome Measures: All patients were reviewed for follow-up, recurrence, risk factors for recurrence, and use of postoperative immunosuppressive prophylaxis. Results: One hundred nine patients were identified, of whom89 were followed up postoperatively at Mayo Clinic with a median follow-up of 3.5 years (range, 1.8 months to 11.9 years). Recurrence was discovered in 54 patients (61%) at a median of 13.1 months (range, 1.3 months to 8.7 years). Forty-four patients (49%) received postoperative immunosuppressive prophylaxis (37 [42%] received azathioprine, 8 [9%] received 6-mercaptopurine, and 3 [3%] received infliximab). In a multivariate model of various risk factors for recurrence, presence of granulomas was the only significant predictor of recurrence (P=.01). The 2-year cumulative recurrence rates in the prophylaxis and nonprophylaxis groups were 37.5% and 52.6%, respectively (log-rank test, P=.87). Conclusions: Recurrence occurred in more than half of the patients with Crohn disease after primary laparoscopic ileocolectomy. In this highly selected patient population, use of immunosuppressive prophylaxis was not associated with a delay in recurrence. Presence of granulomas was the only significant predictor of recurrence. These findings should be further explored in larger and less selected patient populations. [ABSTRACT FROM AUTHOR]

Objective: To determine the optimal surgical management of splenic injury encountered during colectomy. Design: Retrospective review from 1992 to 2007. Setting: Mayo Clinic in Rochester, Minnesota, a tertiary care center. Patients: A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007. Main Outcome Measures: Overall 30-day major morbidity and mortality and overall 5-year survival. Results: Of 13 897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirtyseven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P=.03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes. Conclusions: Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail. [ABSTRACT FROM AUTHOR]

Hypothesis Functional outcome and quality of life in older patients (>55 years) undergoing ileal pouch–anal anastomosis (IPAA) for ulcerative colitis or familial adenomatous polyposis have been incompletely studied. Our aim was to update our understanding on how the age of the patient at the time of surgery influences functional outcome and quality of life after IPAA. Methods From January 1, 1981, to December 31, 2000, two thousand two patients who underwent IPAA were studied. Patients were grouped by age at operation: 45 years or younger (n = 1688), between 46 and 55 years (n = 249), and older than 55 years (n = 65). Mean age was 33.5 years. Postoperative complications, function, and quality of life were assessed with a questionnaire administered annually. Results Follow-up for patients older than 55 years was a mean ± SD of 8.1 ± 4.8 years. Overall, follow-up was a mean of 10.1 ± 5.7 years. The pouch failure rate for patients older than 55 years was 1.6% at 10 years. No statistically significant difference in pouch failure between age groups was observed. Overall, frequent daytime and nighttime incontinence, respectively, occurred in 5.6% and 13.3% of the patients at 10 years. Incontinence was more common in older patients (P = .002 at 3 years). Quality of life as assessed by social activities, work, travel, sexual activity, family relationships, and sports and recreation was not significantly different among age groups. Most patients felt that their condition had improved or that they had no restrictions after IPAA. Conclusions Postoperative complications after surgery seem to be unrelated to age at the time of surgery. Although incontinence may occur more frequently in older patients, IPAA does not adversely affect quality of life in patients older than 55 years. [ABSTRACT FROM AUTHOR]

Discusses the medical and surgical management of chronic ulcerative colitis (CUC), a mucosal inflammatory process limited to the rectum and the colon. Major diseases processes of idiopathic inflammatory bowel disease; Etiology of the diseases; Approximate number of people in the United States diagnosed as having CUC.