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Background Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. Methods This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. Results After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% ( P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. Conclusion Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.

Mental Health Disorders (MHD) are a growing concern nationwide. The significant impact MHD have on surgical outcomes has only recently started to be understood. This literature review investigated how mental health impacts the outcomes of general surgery patients and what can be done to make improvements. Patients with schizophrenia had the poorest surgical outcomes. Mental health disorders increased post-surgical pain, hospital length of stay, complications, readmissions, and mortality. Mental health disorders decreased wound healing and quality of care. Optimizing outcomes will be best accomplished through integrating more effective perioperative screening tools and interventions. Screenings tools can incorporate artificial intelligence, MHD data, resilience and its biomarkers, and patient mental health questionnaires. Interventions include cognitive behavioral therapy, virtual reality, spirituality, pharmacology, and resilience training.

Introduction There is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail. Methods We queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity. Results 430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity. Conclusions Our data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity. Short summary We applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

Perianal Crohn’s disease (CD) is a complex manifestation of CD that affects approximately 10% of patients. The spectrum of disease is quite variable, ranging from relatively mild disease to severe, aggressive manifestations that result in frequent hospitalizations, multiple surgeries, and poor quality of life. Despite significant recent advances in surgical and medical management, treatment remains challenging and frequently requires a multidisciplinary medical-surgical approach. The goal of this article is to review the current literature regarding the work-up, treatment, and future directions of therapy. Crucial features of effective management include the precise identification of manifestations, control of sepsis, limiting rectal inflammation, frequently with use of antitumor necrosis factor agents, and avoidance of extensive surgery.

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, P = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.

Minimizing perioperative fluid administration is a key component of enhanced recovery after surgery protocols (ERAS). Acute kidney injury (AKI) is a major cause of morbidity and mortality in hospitalized patients. Our aim was to assess the association of ERAS with the incidence and severity of AKI in patients undergoing elective colorectal surgery. In this single-study retrospective review, patients undergoing colorectal surgery from 2013 to 2017 were included. Primary endpoint was postoperative AKI. Secondary outcomes were hospital length of stay (LOS) and 30-day readmission. Baseline demographics and procedure types were similar between both groups. AKI was higher in the ERAS versus non-ERAS group (23 vs 9%; P = 0.002). Factors associated with increased risk of AKI on univariate regression included presence of preoperative cardiovascular risk factors (hazard ratio (HR) 3.5; 95% CI 1.3–9.7; P < 0.01), more complex colorectal operations (HR 5.1; 95% CI 1.6–16.1; P < 0.01), and management with an ERAS pathway (HR 2.9; 95% CI 1.5–5.8; P < 0.01). On multi-variable analysis, ERAS remained a significant risk factor for developing AKI (HR 3.44; 95% CI 1.5–7.7; P < 0.01). ERAS patients had a shorter hospital LOS (3.9 vs 5.9 days, P < 00.1) compared with non-ERAS patients, with no difference in 30-day readmission rates (11.5 vs 10.7%; P = 0.98). Although the incidence of AKI is higher in patients treated with ERAS protocols, the majority represent minor elevations in baseline serum creatinine and did not affect the reduction in hospital LOS associated with ERAS. Given the potential association of AKI, however, with increased long-term morbidity and mortality, ERAS protocols should be optimized to prevent postoperative AKI.

Introduction Enhanced recovery after surgery protocols are commonly used, but their utility in patients with inflammatory bowel disease and steroid use is poorly studied. We sought to examine influence of inflammatory bowel disease (IBD) and steroid use on hospital length of stay (LOS) and operative duration in patients undergoing colectomies in the era of ERAS. Methods We performed retrospective review of our institutional National Surgical Quality Improvement Program (NSQIP) registry (2016-2018) for colectomies. We performed 2 distinct analyses to examine influence of steroids and IBD on LOS and operative duration. Multivariable linear regression was used to predict outcomes after adjusting for relevant perioperative features. Results There were 366 patients in the cohort; 17.8% were on steroids and 16.4% had IBD. Patients using steroids had longer LOS (6 vs 4 days, P < .0001). IBD patients had a longer LOS (7 vs 5 days, P < .0001) and longer operative duration (383 min vs 335.5 minute, P = .01) compared to non-IBD patients. On multivariable analysis, steroid use was not associated with increased LOS or operative duration. Inflammatory bowel disease was associated with an increased hospital LOS and operative duration. Discussion Patients on steroids had longer LOS when compared to patients not on steroids. Inflammatory bowel disease regardless of steroid use was found to be a significant risk factor for both increased LOS and operative duration. A closer look at preoperative physiology may help to tailor ERAS protocols in patients with inflammatory conditions.

Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin

Surgical site infections (SSIs) result in patient morbidity and increased costs. The purpose of this study was to determine reasons underlying SSI to enable interventions addressing identified factors. Combining data from the American College of Surgeons National Surgical Quality Improvement Project with medical record extraction, we evaluated 365 patients who underwent colon resection from January 2009 to December 2012 at a single institution. Of the 365 patients, 84 (23%) developed SSI. On univariate analysis, significant risk factors included disseminated cancer, ileostomy, patient temperature less than 36°C for greater than 60 minutes, and higher glucose level. The median number of cases per surgeon was 36, and a case volume below the median was associated with a higher risk of SSI. On multivariate analysis, significant risks associated with SSI included disseminated cancer (odds ratio [OR], 4.31; P < .001); surgery performed by a surgeon with less than 36 cases (OR, 2.19; P = .008); higher glucose level (OR, 1.06; P 5.017); and transfusion of five units or more of blood (OR, 3.26; P 5.029). In this study we found both modifiable and unmodifiable factors associated with increased SSI. Identifying modifiable risk factors enables targeting specific areas to improve the quality of care and patient outcomes.