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Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision.Methods: The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated.Results: 38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%.Conclusion: A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA.Methods: A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively.Results: One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031).Conclusion: Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort. [ABSTRACT FROM AUTHOR]

Background: Colorectal surgical site infections (SSIs) contribute to postoperative morbidity, mortality, and resource utilization. Risk factors associated with colorectal SSI are well-documented. However, quality improvement efforts are informed by national data, which may not identify institution-specific risk factors.Method: Retrospective cohort study of colorectal surgery patients uses institutional ACS-NSQIP data from 2006 through 2014. ACS-NSQIP data were enhanced with additional variables from medical records. Multivariable logistic regression identified factors associated with SSI development.Results: Of 2376 patients, 213 (9.0%) developed at least one SSI (superficial 4.8%, deep 1.1%, organ space 3.5%). Age < 40, BMI > 30, ASA3+, steroid use, smoking, diabetes, pre-operative sepsis, higher wound class, elevated WBC or serum glutamic-oxalocetic transaminase, low hematocrit or albumin, Crohn's disease, and prolonged incision-to-closure time were associated with increased SSI rate (all P < 0.01). After adjustment, BMI > 30, steroids, diabetes, and wound contamination were associated with SSI. Patients with Crohn's had greater odds of SSI than other indications.Conclusion: Institutional modeling of SSI suggests that many previously suggested risk factors established on a national level do not contribute to SSIs at our institution. Identification of institution-specific predictors of SSI, rather than relying upon conclusions derived from external data, is a critical endeavor in facilitating quality improvement and maximizing value of quality investments. [ABSTRACT FROM AUTHOR]

Introduction: Returns to the operating room (ROR) have been suggested as a marker of surgical quality. Increasingly, quality and value metrics are utilized for reimbursement as well as public reporting to inform health care consumers. We sought to understand the etiology of ROR and assess the validity of simple ROR as a quality metric.Methods: This was a single referral center retrospective review of all colon and rectal operations between January 1, 2014 and December 31, 2014. Surgical Systems Nurse + was constructed and validated at our institution for classifying ROR as either an unplanned return to the OR, planned return due to complications, planned staged return, or an unrelated return. The primary outcome was the classification of ROR and total number of ROR within 30 days.Results: Of the 2389 colorectal patients who underwent surgery between January 1, 2014 and December 31, 2014; 214 returned to the operating room within 30 days (9.0%). Among the 214 patients, there were a total of 232 ROR with an average of 1.1 ROR per patient (range 1-4); 90 (38.8%) were unplanned ROR, 49 (21.1%) were planned returns due to complications, 92 (39.7%) were planned staged returns, and 1 (0.4%) were unrelated ROR. The most common reason for an unplanned ROR was an anastomotic leak (n = 21; 9.1%). Overall, unplanned reoperations were rare events (n = 90/2389; 3.8%), largely comprised of patients experiencing an anastomotic abscess or leak (n=21/2389; 0.9%).Conclusions: In a high volume and complexity academic colon and rectal surgery practice, RORs within 30 days occurred after 10.4% of cases. Unplanned ROR were relatively rare and most commonly associated with an anastomotic leak. Since the majority of ROR were planned-staged returns, overall rate of ROR should be questioned as a metric of surgical quality. Perhaps, the anastomotic leak rate may be a better metric to monitor for quality improvement efforts. [ABSTRACT FROM AUTHOR]

Introduction: Primary colorectal sarcomas are a rare entity with anecdotally poor outcomes. We sought to inform surgeons, oncologists, and researchers of the characteristics and outcomes of these understudied and difficult-to-manage tumors.Methods: The National Cancer Data Base (NCDB) was queried for patients with pathologically confirmed primary sarcoma of the colon or rectum (1998-2012). Gastrointestinal stromal tumors were excluded. Unadjusted overall survival was reported using the Kaplan-Meier method. Patients with colorectal adenocarcinoma were used as a comparison cohort.Results: Four hundred thirty-three patients with primary colorectal sarcoma were identified (57.5% leiomyosarcoma subtype). Median age was 63 [inter-quartile range 52, 75] years with 23.1% between the ages of 18 and 50 and 48.7% female. Majority of sarcomas were located in the colon (70.7%). When compared to 696,902 patients with adenocarcinoma, sarcoma patients were younger, had larger tumors, were more likely node negative and rectal in location, and higher grade (all p < 0.001), while sex, race, and comorbidity score were similar (all p > 0.05). Overall survival was lower at 5 years in patients with sarcoma (43.8%) than adenocarcinoma (52.3%, p < 0.001).Conclusion: Primary colorectal sarcomas are rare and present at a younger age and higher grade than adenocarcinoma of the colon and rectum. Survival is significantly worse compared to adenocarcinoma patients. [ABSTRACT FROM AUTHOR]

Background Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patients’ hospital experience. Methods All inpatient, elective colorectal resections with completed HCAHPS surveys at a single institution between June 2012 and April 2015 were identified. HCAHPS measures were analyzed according to published methodologies. Univariate logistic regression evaluated associations of various HCAHPS measures with age, sex, ostomy, approach, diagnosis, and prolonged length of stay (PLOS; ≥7 days). Key driver analysis demonstrated associations between the individual HCAHPS measures and the global hospital rating measure. Results We identified 755 patients. Younger age, inflammatory bowel disease, open approach, ostomy construction, and PLOS were associated with low quality of pain management. Patients with inflammatory bowel disease, open approach, and PLOS had a low overall star score (all P < .05). Care transitions and communication about medications received low scores but were associated highly with the global hospital rating measure. Conclusion Efforts aimed at improving pain management among patients with colorectal resection should focus on patients with inflammatory bowel disease, open operations, ostomies, and PLOS. Improving care transitions and communication about medications are important targets for improvement to increase the overall hospital score. Considering the importance of improving patient-centered outcomes, we suggest that all institutions utilize their existing HCAHPS data in this manner. [ABSTRACT FROM AUTHOR]

Introduction: Safety of synchronous hepatectomy and colorectal resection (CRR) for metastatic colorectal cancer remains controversial. We hypothesized that both the extent of hepatectomy and CRR influences postoperative outcomes.Methods: Prospective 2005-2013 ACS-NSQIP data were retrospectively reviewed for mortality and major morbidity (MM) after (1) isolated hepatectomy, (2) isolated CRR, and (3) synchronous resection for colorectal cancer. Hepatectomy and CRR risk categories were created based on mortality and MM of respective isolated resections. The synchronous cohort was then stratified based on risk categories. Cumulative asynchronous mortality and MM were estimated compared to that observed in the synchronous cohort via unadjusted relative risk and risk difference.Results: There were 43,408 patients identified. Among isolated hepatectomy patients (N = 6,661), trisectionectomy and right hepatectomy experienced the greatest mortality and were defined as "major" hepatectomy. Among isolated CRR patients (N = 35,825), diverted left colectomy, abdominoperineal resection, total abdominal colectomy, and total abdominal proctocolectomy experienced the greatest MM and were defined as "high risk" CRR. Synchronous patients (N = 922) were stratified by hepatectomy and CRR risk categories; mortality and MM varied from 0.9 to 5.0 % and 25.5 to 55.0 %, respectively. Mortality and MM were greatest for patients undergoing "high risk" CRR and "major" hepatectomy and lowest for synchronous CRR and "minor" hepatectomy. As both CRR and hepatectomy risk categories increased, there was a significant trend in increasing mortality and MM in synchronous patients. Additionally, comparison of the synchronous resections versus the estimated cumulative asynchronous outcomes showed that (1) mortality was significantly less after synchronous minor hepatectomy and either low or high risk CRR, and (2) neither mortality nor major morbidity differed significantly after major hepatectomy with either high or low risk CRR.Conclusion: Major morbidity after synchronous hepatic and colorectal resections vary incrementally and are related to both the risk of hepatectomy and CRR. Stratification of outcomes by the hepatectomy and CRR components may reflect a more accurate description of risks. Comparison of synchronous and combined outcomes of individual operations supports a potential benefit for synchronous resections with minor hepatectomy. [ABSTRACT FROM AUTHOR]

Keywords: Proctectomy; Rectal cancer; Crohn's disease; Ulcerative colitis; Quality EN Proctectomy Rectal cancer Crohn's disease Ulcerative colitis Quality 2961 2962 2 11/22/21 20211101 NES 211101 Introduction The Choosing Wisely campaign has called into question the necessity of many medical tests that are routinely ordered but carry significant potential harm or cost.[1] We previously demonstrated that routine postoperative day (POD) 1 labs fit into the category of largely unnecessary testing after elective colectomy and ileostomy reversal,[2] but whether these labs are of value after more technically complex operations such as proctectomy and total proctocolectomy remain unknown. Our study is limited by the lack of a control group of patients undergoing proctectomy or total proctocolectomy who did not have serum labs obtained to determine any differences in their postoperative course. [Extracted from the article]

Introduction We report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS). Methods From August 2009 to August 2014, operative and invasive procedural “Never Events” (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using the 4 levels of error causation described by Reason and 161 HFACS subcategories (nano-codes). Results During the study, approximately 1.5 million procedures were performed, during which 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors ( n = 260) and preconditions to actions ( n = 296) accounted for the majority of the nano-codes across all 4 types of events, with individual cognitive factors contributing one half of the nano-codes. The most common action nano-codes were confirmation bias ( n = 36) and failed to understand ( n = 36). The most common precondition nano-codes were channeled attention on a single issue ( n = 33) and inadequate communication ( n = 30). Conclusion Targeting quality and interventions in system improvement addressing cognitive factors and team resource management as well as perceptual biases may decrease errors and further improve patient safety. These results delineate targets to further decrease never events from our health care system. [ABSTRACT FROM AUTHOR]

The purpose of this randomized controlled trial was to evaluate the effect of postoperative massage in patients undergoing abdominal colorectal surgery. One hundred twenty-seven patients were randomized to receive a 20-min massage (n = 61) or social visit and relaxation session (no massage; n = 66) on postoperative days 2 and 3. Vital signs and psychological well-being (pain, tension, anxiety, satisfaction with care, relaxation) were assessed before and after each intervention. The study results indicated that postoperative massage significantly improved the patients' perception of pain, tension, and anxiety, but overall satisfaction was unchanged. In conclusion, massage may be beneficial during postoperative recovery for patients undergoing abdominal colorectal surgery. Further studies are warranted to optimize timing and duration and to determine other benefits in this clinical setting. [ABSTRACT FROM AUTHOR]

Background/Purpose Identifying quality in pediatric surgery can be difficult given the low frequency of postoperative complications. We compared postoperative events following pediatric surgical procedures at a single institution identified by ACS-NSQIP Pediatric (ACS NSQIP-P) methodology and AHRQ Pediatric Quality Indicators (AHRQ PDIs), an administrative tool. Methods AHRQ PDI algorithms were run on inpatient hospital discharge abstracts for 1257 children in the 2010 to 2013 ACS NSQIP-P at our institution. Four events—pulmonary complications, postoperative sepsis, wound dehiscence and bleeding—were matched between ACS NSQIP-P and AHRQ PDI. Results Events were identified by ACS NSQIP-P in 7.9% of children and by AHRQ PDI in 8.0%. The four matched events were identified in 5.5% and 3.7%, respectively. Specificities of AHRQ PDI ranged from 97% to 100% and sensitivities from 0 to 2%. The largest discrepancy was in bleeding, where AHRQ PDI captured 1 of the 54 events identified by ACS NSQIP-P. None of the 41 pulmonary, sepsis, and wound dehiscence events identified by AHRQ PDI were clinically relevant according to ACS NSQIP-P. Conclusions Adverse events following pediatric surgery are infrequent; thus, additional measures of quality to supplement postoperative adverse events are needed. AHRQ PDIs are inadequate for assessing quality in pediatric surgery. [ABSTRACT FROM AUTHOR]

Background: Colorectal surgery is associated with high rates of surgical site infection (SSI). The National Surgery Quality Improvement Program is a validated, risk-adjusted quality-improvement program for surgical patients. Patient stratification and risk adjustment are associated with Current Procedural Terminology codes and primary disease diagnosis is not considered. Our aim was to determine the association between disease diagnosis and SSI rates. Methods: Data from all 2009 National Surgery Quality Improvement Program institutions were analyzed. ICD-9 codes were used to differentiate patients into cancer (colon or rectal), ulcerative colitis, regional enteritis, diverticular disease, and others. Diagnosis-specific SSI rates were compared with benign neoplasm, which had the lowest rate (8.9%). Logistic regression was performed adjusting for age, body mass index, American Society of Anesthesiologists classification, wound type, and relative value unit. Results: There were 24,673 colorectal procedures, with 1,956 superficial incisional (SSSI), 398 deep incisional (DSSI), and 1,096 organ/space (O/SSSI) infections. Odds ratio (OR) and 95% confidence intervals compared with benign neoplasm diagnosis were computed after adjustment for each diagnosis category. In rectal cancer patients, significantly more SSSI (OR = 1.6; 95% CI, 1.3−2.1; p < 0.0001), DSSI (OR = 2.1; 95% CI, 1.3−3.7; p = 0.006), and O/SSSI (OR = 2.2; 95% CI, 1.6−3.0; p < 0.0001) developed. In diverticular patients, more SSSI (OR = 1.6; 95% CI, 1.3−2.0; p < 0.0001), but not DSSI or O/SSSI, developed. In ulcerative colitis patients, more DSSI (OR = 2.4; 95% CI, 1.2−4.9; p = 0.01), O/SSSI (OR = 2.1; 95% CI, 1.4−3.1; p = 0.0004), but fewer SSSIs, developed. Conclusions: We found that SSI type is associated with the underlying disease diagnosis. To facilitate colorectal SSI-reduction efforts, the disease process must be considered to design appropriate interventions. In addition, institutional comparisons based on aggregate or stratified SSI rates can be misleading if the colorectal disease mix is not considered. [Copyright &y& Elsevier]

Background: Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. Methods: We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. Results: ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. Conclusion: AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance. [Copyright &y& Elsevier]

Purpose: Patients on chronic oral anticoagulation can be challenging to manage in the perioperative period.Methods: Review of patients on warfarin undergoing elective abdominal colon and rectal operations at a single institution from 2000 to 2006.Results: One forty-six patients underwent 165 abdominal procedures. Mean (±SEM) age was 67 ± 1 years; 59% of patients were men. Median estimated blood loss was 200 ml, and 19% received intraoperative blood products while 19% of patients received a postoperative transfusion. Sixteen patients (10%) experienced bleeding complications (three requiring reoperation). No risk factors for bleeding were identified by multivariate analysis (MVA). Five patients (3%) suffered a postoperative thromboembolic event. Preoperative anticoagulation for cerebrovascular disease was a risk factor for thromboembolism (p = 0.03). Overall operative morbidity was 30% with no identifiable risk factor in MVA. Mortality was nil.Conclusion: Postoperative bleeding and thromboembolism in patients on chronic anticoagulation are not insignificant (10% and 3%, respectively). Patients on warfarin for cerebrovascular disease are at increased risk for thromboembolic events postoperatively and should be placed on appropriate prophylaxis and monitored. [ABSTRACT FROM AUTHOR]

Purpose: Primary coloduodenal fistula (CDF) is a rare entity. We review our experience with the management and outcomes of CDF.Methods: This is a retrospective review from 1975 to 2005 of patients with primary CDF. Patients were followed through clinic visits and mail correspondence with a mean (±SE) follow-up of 56 ± 14 months.Results: Twenty-two patients were diagnosed at a mean age of 54 ± 3 years with primary CDF: benign (n = 14) or malignant (n = 8). Benign CDF were due to Crohn's disease (n = 9) or peptic ulcer disease (n = 5); malignant CDF was primarily due to colon cancer (n = 7) plus 1 patient with lymphoma. Indications for operative intervention included intractable symptoms (n = 15), gastrointestinal bleeding (n = 14), and to rule out malignancy (n = 8). Complete resection of malignant CDF with negative margins was achieved in half of patients after en bloc resection. Palliative bypass was performed in those patients with unresectable disease. Thirteen patients with benign CDF had resection of the fistula-2 of these patients required a duodenal bypass. There were no perioperative deaths, and the morbidity rate was 38%. Median survival for patients with malignant CDF was 20 months (range 1-150 months). Two patients with malignant CDF had >5-year survival. All patients with benign CDF who underwent fistula resection had resolution of fistula-related symptoms with one recurrence.Conclusion: Benign CDF is amenable to operative therapy with resolution of symptoms and a low recurrence rate. Complete resection of malignant CDF can impart survival benefit. [ABSTRACT FROM AUTHOR]

Background: Operating rooms (ORs) are resource-intense and costly hospital units. Maximizing OR efficiency is essential to maintaining an economically viable institution. OR efficiency projects often focus on a limited number of ORs or cases. Efforts across an entire OR suite have not been reported. Lean and Six Sigma methodologies were developed in the manufacturing industry to increase efficiency by eliminating non−value-added steps. We applied Lean and Six Sigma methodologies across an entire surgical suite to improve efficiency. Study Design: A multidisciplinary surgical process improvement team constructed a value stream map of the entire surgical process from the decision for surgery to discharge. Each process step was analyzed in 3 domains, ie, personnel, information processed, and time. Multidisciplinary teams addressed 5 work streams to increase value at each step: minimizing volume variation; streamlining the preoperative process; reducing nonoperative time; eliminating redundant information; and promoting employee engagement. Process improvements were implemented sequentially in surgical specialties. Key performance metrics were collected before and after implementation. Results: Across 3 surgical specialties, process redesign resulted in substantial improvements in on-time starts and reduction in number of cases past 5 pm. Substantial gains were achieved in nonoperative time, staff overtime, and ORs saved. These changes resulted in substantial increases in margin/OR/day. Conclusions: Use of Lean and Six Sigma methodologies increased OR efficiency and financial performance across an entire operating suite. Process mapping, leadership support, staff engagement, and sharing performance metrics are keys to enhancing OR efficiency. The performance gains were substantial, sustainable, positive financially, and transferrable to other specialties. [ABSTRACT FROM AUTHOR]

Objective: To report a new technique to reconstruct the abdominal wall at the site of the hernia with 2 separate layers of human acellular dermal matrix (hADM). Parastomal hernia is the most commonly encountered complication of ileal conduit urinary diversion, occurring at a rate of 5%-25%. Multiple methods of parastomal hernia repair, including primary fascial repair, mesh repair, and stoma resiting have been reported, with a wide variety of approaches and materials being used. Methods: Between 2008 and 2009, 4 patients underwent surgical repair of urostomal hernias using hADM (LifeCell, Branchburg, NJ). All were operated on by a single surgeon using a standard technique of open repair whereby the posterior and anterior rectus fascia at the stoma site were reconstructed with hADM. Demographic data, preoperative and intraoperative risk factors, immediate postoperative complications, and hernia recurrence were collected and analyzed. Results: Four patients underwent urostomal hernia repair with Alloderm without intraoperative complications. Mean operative time was 261.25 ± 80.8 minutes. Mean hospital stay was 9 ± 3 days. With an average of 270 ± 104-days'' follow-up, there were no recurrent hernias detected. Conclusions: In patients with urostomal hernia, reconstruction of the stoma site and abdominal wall with hADM appears to be a safe and effective management solution and avoids the difficulty with relocating the urostomy or placing prosthetic material in the site. [Copyright &y& Elsevier]

Background: There have been numerous studies with conflicting results regarding the use of anti-tumor necrosis factor (TNF) therapy and its relationship to postoperative outcome in Crohn disease. The aim of our study was to examine the rate of postoperative morbidity in patients receiving anti TNF therapy in the perioperative period.Methods: All patients undergoing surgery for Crohn disease from 2005 till 2008 were abstracted from a prospective database. Patients undergoing surgery which included a suture or staple line at risk for leaking were selected for the study. A retrospective review of medical records was performed. The study group comprised patients treated with perioperative anti TNF therapy (defined as treatment within 8 weeks preoperatively or up to 30 days postoperatively). The remainder of the patients did not receive perioperative anti TNF therapy. Patient characteristics, disease severity, medication use, operative intervention and 30-day complication were compared between the two groups.Results: Three hundred and seventy patients were selected for analysis in this study, of which 119 received perioperative anti TNF therapy and 251 did not. The groups were similar in baseline characteristics, perioperative risk factors and procedures. The group who received perioperative anti TNF therapy had a more severe disease overall as measured by the American College of Gastroenterology (ACG) categories of disease (50% severe fulminant disease in the perioperative anti-TNF therapy group versus 18% in the group that did not receive perioperative anti-TNF therapy, p < 0.001). There was no significant association of perioperative anti TNF therapy and any postoperative complications (27.9% in anti-TNF group versus 30.1% in no anti-TNF group, p = 0.63) nor intra-abdominal infectious complications (5.0% in anti-TNF group versus 7.2% in no anti-TNF group, p = 0.44). Univariate analysis showed that the only factors associated with an increase in postoperative intra-abdominal infections were age and penetrating disease.Conclusions: The use of anti-TNF therapy in the perioperative period is safe and is not associated with an increase in overall or infectious complications in Crohn disease patients undergoing surgery. [ABSTRACT FROM AUTHOR]

Background: Hand-assisted laparoscopic surgery (HALS) is an established alternative to laparoscopic-assisted surgery, but limited data exist regarding its applicability for colorectal cancer (CRC). We report short-term outcomes in a large series of CRC patients who underwent HALS between 2004 and 2009. Methods: A prospectively maintained database was used to identify all CRC patients. Patients with colon cancer (CC) and rectal cancer (RC) were considered separately. Three patients with synchronous CC and RC were excluded. Data are frequency (%) or median (interquartile range). Results: Between 2004 and 2009, 323 CRC patients underwent a HALS procedure. Median age was 65 (53–73) years, 39% were women, and the median BMI was 27 (24–31) kg/m2. Diagnoses included 194 colon cancers (CC, 56.7% stage I/II), 129 rectal cancers (RC, 62.7% stage I/II). Operative time was less for CC than RC (157 vs 204 min; P < .0001). Conversion to laparotomy occurred in similar proportions of CC and RC cases (14% vs 10%; P = .38); lymph nodes retrieval was also similar (18 vs 18; P = .45). Overall duration of stay was 5 (4–7) days. At 30 days, postoperative complications occurred in similar proportions of CC and RC patients (28% vs 30%; P = .72). There was 1 mortality (0.5%). For the subgroup with 3 year follow-up, (73 CC and 45 RC patients), the overall survival was 80% and 88% (CC and RC, respectively), and disease free survival 79% and 85%, respectively. Conclusion: Colon and rectal cancer can be resected safely using HALS techniques. Conversion rates are low, complication rates expected, durations of hospital stay shorter, and the number of lymph nodes retrieved is high. [Copyright &y& Elsevier]

Background: New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges. Methods: Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n ∼ 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker''s perspective. Results: Standard counting detects 82% of RSS. Bar coding prevents ≥97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS—$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost. Conclusion: Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly “never events.” Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost. [Copyright &y& Elsevier]

Background: Incidence of retained foreign objects (RFOs) after operations is unknown, as many can go unrecognized for years. We reviewed the incidence and characteristics of surgical RFO events at a tertiary care institution during 4 years. Study Design: All RFO events, near misses and actual, reported on an adverse event line during 2003 to 2006 were reviewed. Results: During 2003 to 2006, there were 191,168 operations performed, with 68 reported events resulting in a potential RFO defect rate of 0.356/1,000 patients. After review, 34 patients had no RFOs (near misses) and 34 were actual RFOs, resulting in a true RFO defect rate of 0.178/1,000 operations or approximately 1:5,500 operations. In the near-miss patient, needles were miscounted 76% of the time. In the 34 actual RFO patients, items retained were 23 sponges (68%), 7 miscellaneous other items (20%), 3 needles (9%), and 1 instrument (3%). The 34 actual RFOs occurred in incidents where the count had been reported as correct in 21 patients (62%). In 18 patients where an RFO was eventually discovered, intraoperative imaging detected only 12 objects (67%). In operations involving a body cavity, our practice is to obtain a high-resolution x-ray survey film, in a dedicated x-ray suite, before entering the recovery room. Twenty RFOs were identified from survey films and all occurred in patients with correct counts. No RFOs occurred during emergency or high blood-loss procedures and none resulted in demonstrable clinical harm. Two patients left the hospital with an RFO. Twenty-two patients (64.8%) underwent reoperation, with 1 object not removed, 6 (17.6%) retrieved without operation, and 6 (17.6%) where the clinical decision was not to remove. Conclusions: RFOs at an institution that routinely performs postprocedure x-rays indicate that RFOs can occur more frequently than expected from the literature. The majority occur in patients with correct counts. Relying on counting as the primary mechanism to avoid RFOs is unreliable, and investigating new technologies designed to achieve reliable counts is warranted. [Copyright &y& Elsevier]

Background: Laparoscopic-assisted colectomy (LAC) is not performed widely despite numerous patient benefits. LAC is difficult to perform and the learning curve is steep. Hand-assisted laparoscopy (HALS) permits placement of a hand into the abdomen to assist the dissection. Our aim was to analyze the impact of HALS on a minimal access colectomy (MAC) practice. Study Design: A prospectively maintained database was retrospectively reviewed for all LAC and HALS colectomies. HALS was introduced in November 2003, and analysis was performed for the ensuing 3-year period. Procedure types, conversion rates, operation duration, complications, and length of stay were determined. Results: During the study period, 969 MACs were performed (373 HALS, 596 LAC). Although HALS was used for all types of colorectal resection, it was most commonly used for complex colectomies (left-sided and total colectomies). HALS complex colectomies increased 44% from 2004 to 2005, and 24% from 2005 to 2006. Conversely, LAC complex colectomies decreased 29% (2004 to 2005) and then increased 27% (2005 to 2006). There were no demographic differences between patient groups. For complex colectomies, HALS substantially reduced operative time (mean ± SD; LAC, 258±90minutes; HALS, 242±89minutes; p=0.037) and conversion rate (LAC, 15.3% versus HALS, 3.4%, p < 0.001), with the same complication rate (LAC, 13.6%; HALS, 15.4%; p=0.629). The average length of stay (mean ± SD) was increased 1 day in the HALS group (LAC, 5.0±3.0 days; HALS, 6.0±3.4 days; p < 0.001), likely because of the higher proportion of total colectomies. Conclusions: HALS increased the number of MACs performed. More notably, HALS was used preferentially for complex colectomies. HALS effectively bridges the complexity divide between minimal access and open procedures. HALS may serve as a technology to expand MAC. [Copyright &y& Elsevier]

Background: Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), an antitumor necrosis factor−α antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes. Study Design: A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not. Results: Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio [OR] = 3.5; CI, 1.6−7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1−6.7). Conclusions: CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications. [Copyright &y& Elsevier]

It is well recognized that ileostomy patients suffer from chronic depletion of Na+ through the stoma effluent. In this study we evaluated the effects of ileostomy on messenger RNA levels that encode different Na+/H+ exchanger isoforms (NHE-2 and NHE-3). Loop ileostomies were created in Sprague-Dawley rats. Segments of diverted ileum were harvested for quantitation of mRNA levels encoding these isoforms and the Na+/K+ ATPase in mucosal scrapings and for immunofluorescence microscopy, specifically of the NHE-3 protein. Our studies indicate that as early as 8 days after diversion, NHE-3 gene expression is selectively attenuated in poststomal ileal mucosa. Mucosal morphology remains undisturbed, and the distribution of protein expression along the crypt/villus axis is not altered. Infusion of Na+ or the enterocyte nutrient, glutamine, into the lumen of the diverted segment restores or even augments mRNA levels for NHE-3, again without altering the histologic appearance or distribution of the protein along the crypt/villus axis. These effects are specific because nonpolar osmolytes (mannitol) and related organic nutrients not specific for the enterocyte (i.e., butyrate) have no effect on mRNA levels of NHE-3. Further work is required to understand how the early changes in mRNA contribute to mucosal function and response to luminal diversion. (J Gastrointest Surg 2002;6:387–395.) [ABSTRACT FROM AUTHOR]

Purpose The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) is a clinically-derived, validated tool to track outcomes in surgery. The Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are a set of computer algorithms run on administrative data to identify adverse events. The purpose of this study is to compare complications following orthopedic surgery identified by ACS-NSQIP and AHRQ-PSI. Methods Patients between 2010 and 2012 who underwent orthopedic procedures (arthroplasty, spine, trauma, foot and ankle, hand, and upper extremity) at our tertiary-care, academic institution were identified (n = 3,374). Identification of inpatient adverse events by AHRQ-PSI in the cohort was compared with 30-day events identified by ACS-NSQIP. Adverse events common to both AHRQ-PSI and ACS-NSQIP were infection, sepsis, venous thromboembolism, bleeding, respiratory failure, wound disruption, and renal failure. Concordance between AHRQ-PSI and ACS-NSQIP for identifying adverse events was examined. Results A total of 729 adverse events (21.6%) were identified in the cohort using ACS-NSQIP methodology and 35 adverse events (1.0%) were found using AHRQ-PSI. Only 12 events were identified by both methodologies. The most common complication was bleeding in ACS-NSQIP (18.1%) and respiratory failure in AHRQ-PSI (0.53%). The overlap was highest for venous thromboembolic events. There was no overlap in adverse events for 5 of the 7 categories of adverse events. Conclusions A large discrepancy was observed between adverse events reported in ACS-NSQIP and AHRQ-PSI. A large percentage of clinically important adverse events identified in ACS-NSQIP were missed in AHRQ-PSI algorithms. The ability of AHRQ-PSI for detecting adverse events varied widely with ACS-NSQIP. Clinical relevance AHRQ-PSI algorithms currently are insufficient to assess the quality of orthopedic surgery. [ABSTRACT FROM AUTHOR]

Background: Incidence of retained foreign objects (RFOs) after operations is unknown, as many can go unrecognized for years. We reviewed the incidence and characteristics of surgical RFO events at a tertiary care institution during 4 years. Study Design: All RFO events, near misses and actual, reported on an adverse event line during 2003 to 2006 were reviewed. Results: During 2003 to 2006, there were 191,168 operations performed, with 68 reported events resulting in a potential RFO defect rate of 0.356/1,000 patients. After review, 34 patients had no RFOs (near misses) and 34 were actual RFOs, resulting in a true RFO defect rate of 0.178/1,000 operations or approximately 1:5,500 operations. In the near-miss patient, needles were miscounted 76% of the time. In the 34 actual RFO patients, items retained were 23 sponges (68%), 7 miscellaneous other items (20%), 3 needles (9%), and 1 instrument (3%). The 34 actual RFOs occurred in incidents where the count had been reported as correct in 21 patients (62%). In 18 patients where an RFO was eventually discovered, intraoperative imaging detected only 12 objects (67%). In operations involving a body cavity, our practice is to obtain a high-resolution x-ray survey film, in a dedicated x-ray suite, before entering the recovery room. Twenty RFOs were identified from survey films and all occurred in patients with correct counts. No RFOs occurred during emergency or high blood-loss procedures and none resulted in demonstrable clinical harm. Two patients left the hospital with an RFO. Twenty-two patients (64.8%) underwent reoperation, with 1 object not removed, 6 (17.6%) retrieved without operation, and 6 (17.6%) where the clinical decision was not to remove. Conclusions: RFOs at an institution that routinely performs postprocedure x-rays indicate that RFOs can occur more frequently than expected from the literature. The majority occur in patients with correct counts. Relying on counting as the primary mechanism to avoid RFOs is unreliable, and investigating new technologies designed to achieve reliable counts is warranted. [ABSTRACT FROM AUTHOR]