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Purpose: To describe and evaluate safety and feasibility of the robotic modified Sugarbaker technique with intraperitoneal underlay mesh (IPUM) for repairing parastomal hernias associated with ileal conduits (ICPSH). Methods: This retrospective, single-center cohort study analyzed data from 15 adult patients who underwent robotic ICPSH repair using the modified Sugarbaker IPUM technique between July 2021 and July 2023. The primary endpoints were hernia recurrence rates and 30-day morbidity. Secondary endpoints included length of stay, conversion to open surgery, 30-day readmission, and 30-day reoperation. Results: The mean patient age was 69.1 years, and 53.3% were female. Most patients (86.6%) had undergone radical cystectomy as the index surgery. The mean operative time was 249 min, with no conversions to open surgery. The 30-day complication rate was 26.7%, and the mean hospital stay was 3.6 days. No hernia recurrences, hydronephrosis, rise in creatinine or distended conduit on imaging suggesting poor drainage were observed during a mean follow-up of 15.2 months. Conclusions: The robotic modified Sugarbaker IPUM technique appears safe and feasible for PSH repair in IC patients, with promising short-term outcomes. Further studies with larger cohorts and longer follow-up are needed to confirm its long-term efficacy and establish its role in ICPSH management. [ABSTRACT FROM AUTHOR]

We hypothesized that the recent attention to the opioid epidemic, combined with internal dissemination of data on prescribing practices, impacted our institution’s opioid prescribing at discharge from elective surgery. We reviewed our recent practice to assess whether this increasing awareness resulted in reductions of opioid prescriptions for patients with acute pain. Data on prescribing for patients undergoing elective surgery between 2016 and early 2017 demonstrated that opioid prescribing practices have improved in the recent era without an observed increase in refill rates. Although additional work is needed to further improve standardization and reduce opioid prescribing, these data suggest that increased awareness may be an important first step in improving opioid prescribing practices. [ABSTRACT FROM AUTHOR]

Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear. Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively. In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD. The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events. [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]

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]

BACKGROUND: Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. STUDY DESIGN: Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. RESULTS: A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. CONCLUSIONS: When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals. [ABSTRACT FROM AUTHOR]

Background: The development of major low anterior resection syndrome (LARS) after low anterior resection is severely detrimental to quality of life, yet awareness of it by clinicians and patients and the frequency of treatment of LARS is unclear.Study Design: Patients who underwent low anterior resection for sigmoid or rectal cancer at a tertiary center between 2007 and 2017 (n = 798) were surveyed in 2019 to assess LARS symptoms and report medications or treatment received for LARS. LARS scores were calculated (score range 0-42) and normalized to published data on LARS prevalence in the general population in Europe, stratified by age (<50 or ≥50) and sex.Results: Of the 594 patients (74%) who returned the survey, 255 (43%) were identified as having major LARS (LARS score ≥30). This prevalence was significantly higher than published normative data from Denmark and Amsterdam when stratified by age greater than or less than 50 and sex. Patients with major LARS infrequently reported current use of first-line therapies (antidiarrheal medications 32%, fiber supplements 16%, and both 13%). Only 3% reported receiving second-line therapy of transanal irrigations and/or pelvic floor rehabilitation, and only 1% had undergone third-line therapy of sacral nerve stimulator implantation.Conclusion: Major LARS is common yet seemingly underrecognized by clinicians because less than half of patients are on first-line therapy and practically none are on second- and third-line therapies. Long-term follow-up of patients after low anterior resection, improved preoperative and postoperative education, and continued symptom assessment is necessary to improve treatment of major LARS. [ABSTRACT FROM AUTHOR]

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance. [ABSTRACT FROM AUTHOR]

Background: There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types.Methods: The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP's variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity.Results: We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type.Conclusions: The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting. [ABSTRACT FROM AUTHOR]

To increase the rate of normothermia (core temperature ≥ 36 °C) in patients undergoing gynecologic surgery. The rate of surgical normothermia was evaluated in a single institution. A two-phase quality improvement project was undertaken; Phase 1 included the use of intra-operative room temperature regulation and intra-operative patient warming and Phase 2 included pre-operative patient warming. Clinical characteristics, median temperatures, and rate of normothermia were abstracted for patients in each phase. Cohorts were compared using chi-square and t -tests. The project was performed in two phases, each with a historic and intervention cohort. There were 503 patients in the historical cohort and 636 patients in the intervention cohort in phase 1; there were 291 patients in the historical cohort and 259 patients in the intervention cohort for Phase 2. Patient characteristics and anesthetic type and duration did not differ between cohorts. After intra-operative temperature regulation and patient warming in Phase 1, significantly more patients achieved normothermia (79% versus 68%, P < 0.0001). However operating room staff were more likely to rate the temperature as very hot in 40% of cases post-intervention, compared to only 2% historically. In Phase 2, after the intervention of pre-warming patients, there was no difference in achieving normothermia, 78% versus 83%, P = 0.09. Staff had no statistical difference in personal comfort with the temperature, however did feel efforts were very effective more frequently, 7.7% historic versus 32.7% post-intervention, P < 0.0001. Quality improvement methodology can be applied to pre- and intra-operative decision making to improve rates of surgical patient normothermia. • Intra-operative normothermia is important in maintaining hemodynamic stability, normal clotting, and medication metabolism. • Quality improvement methods can be used in an operating room setting to improve compliance with intra-operative normothermia. • A combination of patient warming and room temperature regulation increases rates of intra-operative normothermia. [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]

Objective: To investigate whether implementing a bundle, defined as a set of evidence-based practices performed collectively, can reduce 30-day surgical site infections.Methods: Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer with bowel resection between January 1, 2010, and December 31, 2012, at an academic center. A perioperative bundle was prospectively implemented during the intervention period (August 1, 2013, to September 30, 2014). Prior established elements were: patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol coverage of incisional area, and cefazolin redosing 3-4 hours after incision. New elements initiated were: sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24-48 hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing phone call. Surgical site infection rates were examined using control charts, compared between periods using χ or Fisher exact test, and validated against the American College of Surgeons National Surgical Quality Improvement Program decile ranking.Results: The overall 30-day surgical site infection rate was 38 of 635 (6.0%) among all cases in the preintervention period, with 11 superficial (1.7%), two deep (0.3%), and 25 organ or space infections (3.9%). In the intervention period, the overall rate was 2 of 190 (1.1%), with two organ or space infections (1.1%). Overall, the relative risk reduction in surgical site infection was 82.4% (P=.01). The surgical site infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer. The American College of Surgeons National Surgical Quality Improvement Program decile ranking improved from the 10th decile to first decile; risk-adjusted odds ratio for surgical site infection decreased from 1.6 (95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1).Conclusion: Implementation of an evidence-based surgical site infection reduction bundle was associated with substantial reductions in surgical site infection in high-risk cancer procedures. [ABSTRACT FROM AUTHOR]

Background: Colorectal surgical site infections (C-SSIs) are a major source of postoperative morbidity. Institutional C-SSI rates are modeled and scrutinized, and there is increasing movement in the direction of public reporting. External validation of C-SSI risk prediction models is lacking. Factors governing C-SSI occurrence are complicated and multifactorial. We hypothesized that existing C-SSI prediction models have limited ability to accurately predict C-SSI in independent data.Study Design: Colorectal resections identified from our institutional ACS-NSQIP dataset (2006 to 2014) were reviewed. The primary outcome was any C-SSI according to the ACS-NSQIP definition. Emergency cases were excluded. Published C-SSI risk scores: the National Nosocomial Infection Surveillance (NNIS), Contamination, Obesity, Laparotomy, and American Society of Anesthesiologists (ASA) class (COLA), Preventie Ziekenhuisinfecties door Surveillance (PREZIES), and NSQIP-based models were compared with receiver operating characteristic (ROC) analysis to evaluate discriminatory quality.Results: There were 2,376 cases included, with an overall C-SSI rate of 9% (213 cases). None of the models produced reliable and high quality C-SSI predictions. For any C-SSI, the NNIS c-index was 0.57 vs 0.61 for COLA, 0.58 for PREZIES, and 0.62 for NSQIP: all well below the minimum "reasonably" predictive c-index of 0.7. Predictions for superficial, deep, and organ space SSI were similarly poor.Conclusions: Published C-SSI risk prediction models do not accurately predict C-SSI in our independent institutional dataset. Application of externally developed prediction models to any individual practice must be validated or modified to account for institution and case-mix specific factors. This questions the validity of using externally or nationally developed models for "expected" outcomes and interhospital comparisons. [ABSTRACT FROM AUTHOR]

Background: Systems that report hospital-based risk-adjusted surgical outcomes are potentially sensitive to the underlying methods used for risk adjustment. If a body of operations has a true level of risk that is higher than the estimated risk, then these operations might generate bias in the output of these reports. The objective of this study was to quantify the impact of unaccounted risk on the results of a surgical outcomes report.Study Design: We constructed a model simulating a universe of 500 hospitals, each providing care to 1,500 patients in a given year. The likelihood of morbidity and mortality for each of these patients was drawn from a random sampling of patients in the American College of Surgeons NSQIP. A single additional hospital was also simulated, within which a certain proportion (proportion varied from 2% to 10%) of patients had a significantly higher (odds ratio varied from 1 to 5) actual likelihood of mortality.Results: The presence of even a small proportion (2%) of patients with unaccounted risk had the potential to greatly increase the likelihood of a hospital being considered a statistical outlier (poor performer). This impact was greater in the assessment of complications than mortality.Conclusions: This study shows that even a small proportion of patients with substantial levels of unaccounted risk can have a dramatic impact on the assessment of hospital-level risk-adjusted surgical outcomes. To avoid the unintended consequences associated with risk-averse behavior from providers, policy should be constructed to address this potential source of bias. [ABSTRACT FROM AUTHOR]

Background Performance measurement has become central to surgical practice. We systematically reviewed all endorsed performance measures from the National Quality Forum, the national clearing house for performance measures in health care, to identify measures relevant to surgical practice and describe measure stewardship, measure types, and identify gaps in measurement. Study Design Performance measures current to June 2014 were categorized by denominator statement as either assessing surgical practice in specific or as part of a mixed medical and surgical population. Measures were further classified by surgical specialty, Donabedian measure type, patients, disease and events targeted, reporting eligibility, and measure stewards. Results Of 637 measures, 123 measures assessed surgical performance in specific and 123 assessed surgical performance in aggregate. Physician societies (51 of 123, 41.5%) were more common than government agencies (32 of 123, 26.0%) among measure stewards for surgical measures, in particular, the Society for Thoracic Surgery (n = 32). Outcomes measures rather than process measures were common among surgical measures (62 of 123, 50.4%) compared with aggregate medical/surgical measures (46 of 123, 37.4%). Among outcomes measures, death alone was the most commonly specified outcome (24 of 62, 38.7%). Only 1 surgical measure addressed patient-centered care and only 1 measure addressed hospital readmission. We found 7 current surgical measures eligible for value-based purchasing. Conclusions Surgical society stewards and outcomes measure types, particularly for cardiac surgery, were well represented in the National Quality Forum. Measures addressing patient-centered outcomes and the value of surgical decision-making were not well represented and may be suitable targets for measure innovation. [ABSTRACT FROM AUTHOR]

Background: Fast-track (FT) postoperative protocols have been shown to be highly beneficial in open colectomy. Some have questioned the necessity of an FT protocol in the setting of laparoscopic colectomy because hospital stays are short and morbidity is low compared with open surgery. We set out to determine whether an FT protocol has any utility in the setting of elective laparoscopic colectomy. Study Design: A retrospective review was conducted on a cohort of 334 patients who underwent elective laparoscopic sigmoid resection for diverticulitis from 1998 to 2008, at Mayo Clinic, a tertiary care center in Rochester, MN. There were 235 patients who were managed with traditional postoperative care, and 99 who were managed with an FT protocol initiated in 2006. The main outcomes measures were time to soft diet, length of stay, overall morbidity, and readmission rate. Results: Times to soft diet (mean 2.3 vs 3.6 days), and first bowel movement (mean 2.6 vs 3.5 days) were shorter in the FT group (p < 0.001). The median lengths of stay were 3 days (interquartile range 3 to 4 days) and 5 days (interquartile range 4 to 6 days) for the FT and non-FT groups, respectively (p < 0.001). Morbidity was significantly lower in the FT group compared with the non-FT group (15.2% vs 25.5%, p < 0.03). The 30-day readmission rate was 2.9% for the FT group and 7.6% for the non-FT group (p = NS). There were no deaths in either group. Conclusions: Even in patients undergoing laparoscopic colectomy, FT protocols further improve the speed of gastrointestinal recovery, shorten the length of stay, and decrease morbidity. [ABSTRACT FROM AUTHOR]