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Background: Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery., Methods: The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach., Results: A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group., Conclusions: Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

Background: The American College of Surgeons Surgical Risk Calculator was developed to improve risk stratification and surgical quality but has not been studied at the institutional level for specific disease states, like ulcerative colitis (UC)., Methods: UC patients undergoing colorectal resection had predicted risk calculator data compared with actual outcomes for length of stay (LOS), complications, reoperation, and death. Main outcome measures were the difference in actual vs predicted outcomes., Results: Seventy patients were evaluated. The actual and predicted mean LOS was identical, but not representative of the actual LOS picture, which had 10 LOS outliers (14.3%). The actual incidence of any complication (P < .001) and major complications (P < .001) was higher than predicted. The most common complications actually encountered-intrabdominal abscess (14.3%), postoperative ileus (7.2%), and anastomotic leak (5.7%), were not even calculated by the tool., Conclusions: For UC, the calculator poorly evaluates relevant risks, complications, and is greatly impacted by outliers. These limitations caution use for surgical quality reporting and determining specific patient outcomes, at least in UC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA., Methods: A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group., Results: A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p < 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p < 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p < 0.001)., Conclusions: Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.

Background: Our goal was to evaluate the learning curve for transversus abdominis plane (TAP) block placement and identify issues that impede successful placement., Methods: Three novices were prospectively evaluated performing ultrasound-guided TAP blocks in 10 consecutive patients. Operators were assessed on medication knowledge, setup/placement, procedural steps, and performance time. Times were compared to an expert for efficiency and competence. The main outcome measures were procedures needed for competence and variables associated with increased coaching/procedure time., Results: In the 30 patient sample, the mean body mass index (BMI) was 30.9 (standard deviation [SD], 5.79). Fifteen patients were obese (BMI > 30), seven (23.3%) super obese (BMI > 35), and 15 had prior abdominal surgery. The mean setup time was 107.5 s (SD, 87), right-side placement was 131.8 s (SD, 60.3), left-side placement 114.8 s (SD, 40.5), and total time 354 s (SD, 111). By the second attempt, all operators were fluent in the medication and setup. At block 3, operators 1 and 3 reached competence in performance time; by block 4, all three operators reached time competence. After reaching competence, outliers in procedure times were only experienced for extremes in BMI (<20 and >35). Additional coaching was needed in four patients with prior abdominal surgery to decipher the correct planes., Conclusions: Based on our pilot, by four attempts, novices reach appropriate speeds with progressively less coaching to safely and efficiently place TAP blocks. Extremes of BMI and prior abdominal surgery impact procedural time and may required additional coaching to facilitate placement. Given the promising results, further work on developing best practices for education and implementation is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: There is an increasing emphasis on optimizing and measuring surgical quality. The safety and efficacy of minimally invasive techniques have been proven; however, direct comparison of outcomes across platforms has not been performed. Our goal was to compare operative times and quality across three minimally invasive platforms in colorectal surgery., Methods: A prospective database was reviewed for elective minimally invasive surgery (MIS) cases from 2008 to 2014. Patients were stratified into multiport laparoscopic, single-incision laparoscopic (SILS) or robotic-assisted laparoscopic approaches (RALS). Demographics, perioperative, and postoperative outcomes were analyzed. Multivariate regression analysis was used to predict the demographic and procedural factors and outcomes associated with each platform. The main outcome measures were operative time and surgical quality by approach., Results: A total of 1055 cases were evaluated-28.4 % LAP, 18.5 % RALS, and 53.1 % SILS. RALS had the most complex patients, pathology, and procedures. The main diagnosis for RALS was rectal cancer (49.5 %), patients predominantly underwent pelvic surgery (72.8 %), had higher rates of neoadjuvant chemoradiation (p < 0.001) and stoma creation (p < 0.001). RALS had the longest operative time and highest complication and readmissions rates (all p < 0.001). Multiport patients were older than SILS and RALS (p = 0.021), had the most intraoperative complications (p < 0.001), conversions (p < 0.001), and had the longest length of stay (p = 0.001). SILS had the shortest operative times (p < 0.001), length of stay (p = 0.001), and lowest rates of complications (p < 0.001), readmissions (p < 0.001), and unplanned reoperation (p = 0.014). All platforms offered high quality (HARM score 0) from overall short LOS, low readmission, and mortality rates., Conclusions: Multiport, RALS, and SILS each serve a distinct demographic and disease profile and have predictable outcomes. All have risks and benefits, but offer overall high-quality care with a composite of LOS, readmission, and mortality rates. Operative times were directly associated with readmission rates. As all three platforms offer good quality, the choice of which MIS approach to use should be guided by demographics and disease process.

Background: Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series., Study Design: A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014. Demographic, perioperative, short-term outcomes, and recurrence data were analyzed., Results: There were 75 patients with 76 lesions analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m(2) (SD 4.7 kg/m(2)). Median American Society of Anesthesiologists (ASA) score was 2 (range 1 to 4). There were 59 benign (77.3%) and 17 malignant (22.7%) lesions: 6 pT0, 6 pT1, 4 pT2, and 1 pT3. Median lesion distance from the anal verge was 10 cm (range 6 to 16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intraperitoneal entry; all were closed transanally, but 2 had temporary diverting ileostomies fashioned to ensure healing. Median length of stay was 1 day (range 0 to 6). One patient had a fragmented lesion (1.3%). Five patients had positive margins: 2 in palliative pT2 resections, and 3 in pT1, pT2, and gastrointestinal stromal tumor (GIST) patients. They were managed with radical resection (pT1 and pT2 lesions) and surveillance/medical oncology (GIST). Postoperatively, 3 patients had complications (bleeding, rectal stricture, and recto-vaginal fistula), and all were managed nonoperatively. After median follow-up of 39.5 months (range 10.5 to 65.3 months), 1 pT1 patient with negative margins developed a local recurrence and underwent salvage APR., Conclusions: Transanal minimally invasive surgery is a viable option for excision of benign or early stage rectal masses, with mid-term oncologic outcomes comparable to those of radical resection. Further, TAMIS minimizes the morbidity and can allow more patients to benefit from the minimally invasive approach., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Many benefits of minimally invasive surgery are lost in the obese, but robotic-assisted laparoscopic surgery (RALS) may offer advantages in this population. Our goal was to compare outcomes for RALS in obese and non-obese patients., Methods: A prospective database was reviewed for colorectal resections using RALS. Patients were stratified into obese (BMI > 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)), then case-matched for comparability. The main outcome measures were operative time, conversion rate, length of stay and complication, readmission, and reoperation rates between groups., Results: Forty-five patients were evaluated in each cohort. The BMI was significantly different (p < 0.01). All other demographics were well matched. There were no significant differences in operative time (p = 0.86), blood loss (p = 0.38), intraoperative complications (p = 0.54), or conversion rates (p = 0.91) across cohorts. Length of stay was comparable between groups (p = 0.45). Postoperatively, the complication (p = 0.87), readmission (p = 1.00), and reoperation rates (p = 0.95) were similar. There were no mortalities. For malignant cases (37.8 %), the lymph node yield (p = 0.48) and positive margins (p = 1.00) were similar and acceptable in both cohorts., Conclusions: In our matched RALS series, perioperative and postoperative outcomes were similar between obese and non-obese patients undergoing colorectal surgery. RALS is a feasible option in the surgical setting of the obese patient. Further controlled studies are warranted to explore the full benefits.

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

Background: Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS offers several patient-related benefits over multiport laparoscopy. However, its use in obese patients has been limited from concerns of technical difficulty, oncologic compromise, and higher complication and conversion rates. Our objective was to evaluate the feasibility and efficacy of SILS for colectomy in obese patients., Methods: Review of a prospective database identified patients undergoing elective colectomy using SILS from 2009 to 2014. They were stratified into obese (BMI ≥ 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)) and then matched on patient characteristics, diagnosis, and operative procedure. Demographic and perioperative outcome data were evaluated. The primary outcome measures were operative time, length of stay (LOS), and conversion, complication, and readmission rates for each cohort., Results: A total of 160 patients were evaluated-80 in each cohort. Patients were well matched in demographics, diagnosis, and procedure variables. The obese cohort had significantly higher BMI (p < 0.001) and ASA scores (p = 0.035). Operative time (176.9 ± 64.0 vs. 144.4 ± 47.2 min, p < 0.001) and estimated blood loss (89.0 ± 139.5 vs. 51.6 ± 38.0 ml, p < 0.001) were significantly higher in the obese. There were no significant differences in conversion rates (p = 0.682), final incision length (p = 0.088), LOS (p = 0.332), postoperative complications (p = 0.430), or readmissions (p = 1.000) in the obese versus non-obese. Further, in malignant cases, lymph nodes harvested (p = 0.757) and negative distal margins (p = 1.000) were comparable across cohorts., Conclusions: Single-incision laparoscopic colectomy in obese patients had significantly longer operative times, but comparable conversion rates, oncologic outcomes, lengths of stay, complication, and readmission rates as the non-obese cohorts. In the obese, where higher morbidity rates are typically associated with surgical outcomes, SILS may be the ideal platform to optimize outcomes in colorectal surgery. With additional operative time, the obese can realize the same clinical and quality benefits of minimally invasive surgery as the non-obese.

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.

Background: Financial pressures have limited the ability of providers to use medication that may improve clinical outcomes and patient satisfaction. New interventions are often fraught with resistance from individual cost centers. A value realization tool (VRT) is essential for separate cost centers to communicate and comprehend the overall financial and clinical implications of post-surgical pain management medication interventions (PSMI). The goal was to describe development of a VRT., Methods: An evaluation of common in-patient PSMI approaches, impacts, and costs was performed. A multidisciplinary task force guided development of the VRT to ensure appropriate representation and relevance to clinical practice. The main outcome was an Excel-based tool that communicates the overall cost/benefit of PSMI for the post-operative patient encounter., Results: The VRT aggregated input data on costs, clinical impact, and nursing burden of PSMI assessment and monitoring into two high-level outcome reports: Overall Cost Impact and Nurse & Patient Impact. Costs included PSMI specific medication, equipment, professional placement, labor, overall/opioid-related adverse events, re-admissions, and length of stay. Nursing impact included level of practice interference, job satisfaction, and patient care metrics. Patient impact included pain scores, opioid use, PACU time, and satisfaction. Reference data was provided for individual institutions that may not collect all variables included in the VRT., Conclusions: The VRT is a valuable way for administrators to assess PSMI cost/benefits and for individual cost centers to see the overall value of individual interventions. The user-friendly, decision-support tool allows the end-user to use built-in referenced or personalized outcome data, increasing relevance to their institutions. This broad picture could facilitate communication across cost centers and evidence-based decisions for appropriate use and impacts of PSMI.

Background: Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery., Methods: Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group., Results: A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates., Conclusions: SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Enhanced recovery pathways (ERPs) are standardized, multidisciplinary approaches to caring for patients with a goal of decreasing length of stay and care costs without negatively affecting patient outcomes. One facility successfully implemented ERPs for patients undergoing abdominal surgery. For implementation to be successful, nurses were found to be key in providing education, perioperative care, and postoperative evaluation, as well as cost containment. The implementation team collaborated to define, design, implement, and audit an ERP for surgical services. Initial audits demonstrated an increase in compliance with order set use (61% to 93%) and use of ERPs more than standardized order sets (< 1% to 27%), as well as decreased use of daily laboratory orders (94% to 62%) and elimination of automatically ordered laboratory tests (38% to 0%). These results led to the conclusion that the nurse's role is essential for education and successful use of the pathways and that best practices for developing ERPs requires consistency across the care team, diligence to ensure compliance, and use of an audit tool for quality improvement., (Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

As surgical techniques continue to move towards less invasive techniques, single incision laparoscopic surgery (SILS), a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery, was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis, postoperative pain, recovery time, and quality of life at the drawback of higher technical skill required. In this article, we review the history, describe the available technology and techniques, and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.

Background: Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS has comparable or improved outcomes compared to multiport laparoscopy but technical limitations when operating in the pelvis. To address these limitations, we developed an innovative SILS+1 approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for SILS and SILS+1 in lower abdominal and pelvic colorectal surgery., Methods: Review of a prospectively maintained database identified patients who underwent an elective reduced port laparoscopic lower abdominal/pelvic colorectal procedure from 2009 to 2014. Cases were stratified by approach: SILS versus SILS+1 then matched 1:2 on age, gender, body mass index (BMI), comorbidity, and procedure. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates., Results: One hundred thirty-two reduced port AR/LAR patients were evaluated-44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9 % SILS, 87.5 % SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4 % SILS, 88.2 % SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p = 0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD 70.0], p = 0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS+1 compared to SILS (1.1 vs. 11.4 %, p = 0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group., Conclusions: SILS+1 facilitates pelvic and lower abdominal colorectal surgery, with shorter operative times and lower conversion rates. The additional port improved visualization and outcomes without any impact on length of stay, readmission, or complication rates.

Laparoscopy was the most significant technologic advance in colorectal surgery in the last quarter century. The safety, feasibility and oncologic equivalence have been proven, and undisputed clinical benefits have also been demonstrated over open approaches. Despite proven benefits, laparoscopic has not dominated the market, especially for colon and rectal cancer cases. Adaptations in laparoscopic technique were developed to increase use of minimally invasive surgery. Concurrently, there has been a paradigm shift toward less invasive technologies to further optimize patient outcomes. From these needs, hand assisted laparoscopic surgery (HALS), single incision laparoscopic surgery (SILS), and robotic assisted laparoscopic surgery (RALS) were applied to colorectal surgery. Each platform has unique costs and benefits, and similar outcomes when likened to each other in comparative studies. However, conventional laparoscopy, HALS, SILS, and RALS actually serve a complementary role as tools to increase the use of minimally invasive colorectal surgery. The goal of this paper is to review the history, current status, technical specifications, and evolution of the major minimally invasive platforms for colorectal surgery.

Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcomes of multiport laparoscopy. Multiple studies have demonstrated the safety and feasibility of SILS for both benign and malignant colorectal disease. SILS provides the potential for improved cosmesis, postoperative outcomes, and patient quality of life. However, widespread use has been limited by technical demands and lack of an evidence and competency-based curriculum.

Purpose: The purpose of this study is to report the outcomes of an algorithm-based multidisciplinary treatment approach to rectourethral fistula., Methods: This study is a retrospective review of a prospectively collected database at a tertiary center of all consecutive patients treated between 2003 and 2013., Results: Thirty males (mean age 63 years) were reviewed. Prostate cancer treatment was the most common fistula etiology (97%). Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47%). The rate of fecal diversion was 67%. During a mean follow-up of 72 months, healing rate was 90% and recurrence rate 0%. Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion and 6 (20%) following fecal diversion. Thirteen patients (43%) required definitive intervention. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Only 2 patients (7%) required an abdominal approach (positive oncologic margins or non-functioning bladder). Fifteen out of the 20 patients (75%) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17%. Long-term urinary incontinence was noted in 11 patients (37%). Six patients (20%) required permanent urinary diversion or drainage catheters., Conclusions: Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent.

Background: The American College of Surgeons NSQIP risk calculator was developed from multi-institutional clinical data to estimate preoperative risk. The impact of outliers has the potential to greatly affect predictions. Although the effect of outliers is minimized in large series, their impact on the individual provider or institution could be profound. No previous study has assessed the risk calculator for a single institution or provider, including outliers. Our goal was to evaluate the accuracy of the predicted outcomes at a single institution., Study Design: Laparoscopic colectomies performed by two colorectal surgeons at a tertiary referral center were prospectively evaluated using the risk calculator. Predicted outcomes were compared with actual outcomes for length of stay (LOS), complications, return to the operating room, and death. Main outcomes measures were differences in actual vs predicted outcomes., Results: One hundred and sixteen patients were included. Actual LOS was higher than predicted (mean ± SD 4.22 ± 5.49 days vs predicted 4.11 ± 1.18 days; p = 0.0001). Four outliers with multiple complications had an LOS >3 SDs from the mean. After removing these, observed LOS was significantly shorter than predicted (adjusted LOS mean ± SD 3.31 ± 2.30 days vs predicted 4.05 ± 1.14 days; p = 0.002). Occurrence of any complication was significantly lower than predicted (17.3% vs 19.4%; p = 0.05). Rates of major complications (13.2% vs 19.4%; p = 0.009) and surgical site infections (9.8% vs 11.8%; p = 0.006) were also significantly lower than predicted. There were no significant differences in death, urinary tract infection, renal failure, and reoperation rates., Conclusions: Although the risk calculator was effective for evaluating average surgical-risk patients, it does not accurately predict outcomes in a small percentage of patients when one or more serious complications occur. Addition of surgeon- and patient-specific data via the American College of Surgeons case-logging system could better adjust for these areas., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated., Methods: A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation., Results: Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma., Conclusions: Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The overall aim was to develop and validate a risk prediction score for laparoscopic colorectal surgery training cases., Background: Published risk prediction scores are not transferable between hospitals because they are derived from a single institution's data and are not designed for use in training situations., Methods: Cases from the prospectively collected database of the National Training Programme in Laparoscopic Colorectal Surgery, between July 2008 and July 2012, were analyzed. Independent risk factors for conversion were identified by the logistic regression. Converting the odds ratios into integers created a risk prediction score for conversion. The clinical impact of this score was investigated by comparing postoperative complications and the level of trainer input in high- and low-risk cases. To study whether adverse outcomes in predicted high-risk cases occur outside the National Training Programme in Laparoscopic Colorectal Surgery, 2 external data sets were examined., Results: A total of 2341 cases carried out in 42 hospitals were analyzed. Significant risk factors for conversion were body mass index, American Society of Anesthesiology classification, male sex, prior abdominal surgery, and resection type. At a risk score of more than 6, complication rates increased, including mortality (2.9% vs 0.5%, P < 0.001), anastomotic leak (4.3% vs 1.4%, P = 0.002), and a higher level of trainer input (32.2% vs 19.9% of cases, P < 0.001). Analysis of 786 external cases showed that high-risk cases had higher conversion (18.8% vs 7.1%, P < 0.001), overall complication (36.4% vs 15.0%, P < 0.001), and leak rates (4.0% vs 1.3%, P = 0.015)., Conclusions: A risk predication score to facilitate case selection in laparoscopic colorectal surgery training was developed and validated.

Background: Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections., Study Design: Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates., Results: Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series., Conclusions: Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Superior early pain control has been suggested with transversus abdominis plane blocks, but evidence-based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking., Objective: The aim of this study was to determine whether transversus abdominis plane blocks improve early postoperative outcomes in patients undergoing laparoscopic colorectal resection already on an optimized enhanced recovery pathway., Design: This study is based on a prospective, randomized, double-blind controlled trial., Settings: The trial was conducted at a tertiary referral center., Patients: Patients undergoing elective laparoscopic colorectal resection were selected., Interventions(s): Patients were randomly assigned to receive either a transversus abdominis plane block or a placebo placed intraoperatively under laparoscopic guidance. All followed a standardized enhanced recovery pathway. Patient demographics, perioperative procedures, and postoperative outcomes were collected., Main Outcome Measures: Postoperative pain and nausea/vomiting scores in the postanesthesia care unit and department, opioid use, length of stay, and 30-day readmission rates were measured., Results: The trial randomly assigned 41 patients to the transversus abdominis plane block group and 38 patients to the control group. Demographic, clinical, and procedural data were not significantly different. In the postanesthesia care unit, the transversus abdominis plane block group had significantly lower pain scores (p < 0.01) and used fewer opioids (p < 0.01) than the control group; postoperative nausea/vomiting scores were comparable (p = 0.99). The transversus abdominis plane group had significantly lower pain scores on postoperative day 1 (p = 0.04) and throughout the study period (p < 0.01). There was no significant difference between groups in postoperative opioid use (p = 0.65) or nausea/vomiting (p = 0.79). The length of stay (median, 2 days experimental, 3 days control; p = 0.50) and readmission rate (7% experimental, 5% control, p = 0.99) was similar across cohorts., Limitations: This study was conducted a single center., Conclusions: Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. However, the blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.

Objective: Two studies evaluated efficacy and safety of tanezumab versus naproxen for treatment of knee or hip osteoarthritis (OA)., Methods: Randomized controlled studies [NCT00830063 (Study 1015, n=828) and NCT00863304 (Study 1018, n=840)] of subjects with hip or knee OA compared intravenous tanezumab (5 mg or 10 mg) to placebo and naproxen (500 mg twice daily). Coprimary outcomes were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain, WOMAC Physical Function (0-10 numerical rating scale), and patient's global assessment of OA at Week 16., Results: In both studies, tanezumab reduced pain versus placebo [least squares mean differences, 95% CI, tanezumab 5 mg: -1.21 (-1.72, -0.70); -1.13 (-1.65, -0.62); tanezumab 10 mg: -0.91 (-1.42, -0.40); -0.80 (-1.32, -0.29)], and improved function and global scores. Tanezumab 5 mg produced greater pain reduction [-0.76 (-1.28, -0.25); -0.69 (-1.21, -0.17)], and favorable functional and global outcomes versus naproxen. Pain reductions with tanezumab 10 mg versus naproxen did not reach significance, unlike functional (both studies) and global (1 study) outcomes; thus, tanezumab 10 mg was not superior to naproxen, and predefined statistical testing procedures were not met, allowing for conclusion of superiority of tanezumab 5 mg over naproxen despite replicated favorable coprimary outcomes. Tanezumab was associated with greater incidence of peripheral sensory adverse events (paresthesia, hyperesthesia, hypoesthesia, burning sensation), pain in extremity, peripheral edema, and arthralgia. Overall frequency and discontinuations as a result of adverse events were similar to placebo and naproxen., Conclusion: Tanezumab provides efficacious treatment of knee or hip OA and may have therapeutic utility in patients with OA who experience inadequate analgesia with nonsteroidal antiinflammatory drugs.

Background: Our objective was to evaluate ileostomy reversal patients managed with a standardized enhanced recovery pathway to identify factors associated with readmissions., Methods: Prospective review database identified ileostomy reversal patients. Variables for the index admission and readmission were evaluated., Results: Three hundred thirty-two patients were analyzed. The primary diagnosis was colorectal cancer (57.6%). Thirteen percent of the patients were discharged by postoperative day (POD) 1, 47% by POD 2, and 65% by POD 3. The complication rate was 16.8%. The main complication was ileus/small bowel obstruction (n = 27). Thirty-day readmission rate was 12.4% (n = 41); small bowel obstruction (n = 27) was the most frequent readmission diagnosis. The median readmission POD was 7. Only 1 patient had a follow-up visit before readmission. The median readmission length of stay was 4 days., Conclusions: Most ileostomy reversal readmissions occur before the first follow-up and stem from preventable causes. An enhanced recovery pathway modification may improve outcomes and utilization in this group., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A noncontrolled, randomized, multicenter study (NCT00924664) evaluated long-term safety and effectiveness of tanezumab in patients with chronic low back pain following a randomized placebo- and active-controlled parent study that evaluated analgesic efficacy. Patients were randomized to tanezumab 10mg (n=321) or 20mg (n=527) administered at 8-week intervals via 3 intravenous injections followed by 4 subcutaneous injections. Effectiveness analyses included change from parent study baseline in Brief Pain Inventory Short Form, Roland Morris Disability Questionnaire, and Patient's Global Assessment of low back pain. Safety assessments included adverse event documentation, physical/neurological examinations, and laboratory tests. Mean treatment duration during the extension study was 194 and 202 days with tanezumab 10 and 20mg, respectively. Both tanezumab doses provided similar and sustained improvements in all effectiveness outcomes. The most frequently reported adverse events were arthralgia, paresthesia, and hypoesthesia. Adverse events initially described as osteonecrosis were reported in 6 patients (tanezumab 10mg, n=2; tanezumab 20mg, n=4); 9 additional patients (tanezumab 10mg, n=7; tanezumab 20mg, n=2) underwent total joint replacement (TJR). A blinded, independent adjudication committee reviewed all 6 patients with reported osteonecrosis and 4 of the 9 patients undergoing TJR. Adjudication outcomes were osteonecrosis (n=0), worsening osteoarthritis (n=5; 1 rapidly progressive), and another diagnosis or indeterminate (n=5). Tanezumab 10mg had better tolerability than tanezumab 20mg, and may represent an effective long-term treatment for chronic low back pain., (Copyright © 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches., Methods: A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach., Results: The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77%) and 19 open (23%) procedures. Nine laparoscopic procedures (14.5%) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2%; P = 0.450) and overall survival periods (93.5 vs. 90.9%; P = 0.766). The local recurrence rate was 2.5%., Conclusions: Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.

Background and Objectives: The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes., Methods: Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach., Results: Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43)., Conclusions: LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.

Objective: To develop a measurement tool based on HospitAl stay, Readmission, and Mortality rates (HARM) score, which is easily calculated from routine administrative data. Secondary goals were to validate the HARM score on a national inpatient sample., Background: Concerns about patient safety, quality, and health care costs have increased demand for outcome measurement. Performance metrics such as Surgical Care Improvement Project and National Surgical Quality Improvement Program have been described, but they require significant personnel and expenses to maintain., Methods: A national inpatient database was reviewed for all colectomy discharges from 2010 to 2011. Cases were stratified into emergent and elective. For each discharge, a 1 to 10 score was calculated on the basis of length of stay, vital status, and 30-day readmissions. The HARM score was correlated to the complication rate to test validity, and bootstrapping was used to test reliability., Results: A total of 81,622 colectomy discharges were evaluated: 44% emergent and 56% elective. The mean HARM score was 3.04 (SD = 0.57) for emergent and 2.64 (SD = 0.65) for elective cases. For hospitals with a HARM score of less than 2, 2 to 3, 3 to 4, and 4+, the mean complication rates were 30.3%, 41.9%, 49.3%, and 56.6% (emergent) and 15.2%, 18.2%, 24.0%, and 35.6% (elective), respectively. Pearson correlation coefficients for the mean score and the complication rate were 0.45 (P < 0.01) for elective and emergent cases. Bootstrapping correlation demonstrated reliability for emergent and elective cases., Conclusions: The HARM score is easy, reliable, and valid for assessing quality in colorectal surgery. It may provide a low-cost solution for comparative quality assessment in surgery focused on true outlier performance rather than process or clinical outcome metrics alone.

Background: There is an increasing trend to use laparoscopy for rectal cancer surgery. Although laparoscopic and open rectal resections appear oncologically equivalent, there is little information on the cost of different surgical approaches. With the current health care crisis and the importance of optimizing health care resources and patient outcomes, the cost of care is an important factor., Objective: The aim of this study was to evaluate the cost-effectiveness of laparoscopy in rectal cancer., Design: This was a case-matched study., Settings: This study was conducted at a tertiary referral center., Patients: Patients undergoing elective rectal cancer resection between 2007 and 2012 were selected., Methods: A review of a prospective database for elective laparoscopic rectal cancer resections was performed. Laparoscopic cases were matched to open cases based on age, BMI, operative procedure, and diagnostic-related group., Main Outcome Measures: The primary outcomes measured were the cost of care, hospital length of stay, discharge disposition, readmission, postoperative complications, and mortality rates., Results: Two hundred fifty-four matched cases were included in the analysis: 125 laparoscopic (49%) and 129 open (51%). The cTNM stage (p = 0.39), tumor distance from the anal verge (p = 0.07), and rate of neoadjuvant therapy received between the laparoscopic and open groups were similar (p = 0.12). Operating time (p< 0.01) and cost per operating room minute (p = 0.04) were significantly higher in the open group. The groups were oncologically equivalent, based on circumferential resection margin (p = 0.15). The laparoscopic group had a significantly shorter length of stay (p < 0.01) and lower total hospital cost (p < 0.01). Postoperative complications, 30-day readmission, reoperation, and mortality rates were similar. However, significantly more patients undergoing open resection required intensive care unit care (p = 0.03), skilled nursing (p = 0.03), or home care services (p < 0.01) at discharge., Limitations: This investigation was conducted at a single institution and it is a retrospective study with potential bias., Conclusions: Laparoscopy is cost-effective for rectal cancer surgery, improving both health care expenditures and patient outcomes. For selected patients, laparoscopic rectal cancer resection can reduce length of stay, operating time, and resource utilization.

Background: Unplanned readmissions after colorectal surgery impact patient and financial outcomes. Our goal was to identify factors related to readmission in ostomy reversal patients., Methods: Review of a prospective department database was performed from 2006 to 2012 to identify patients who underwent an ostomy reversal. Patients were stratified into nonreadmitted and readmitted within 30 days of ostomy reversal. The main outcome measures were predictors of readmission and characteristics of patients readmitted and not readmitted., Results: A total of 351 ostomy reversals (86 % ileostomy and 14 % colostomy) were analyzed; 44 patients were readmitted (12.5 %). Readmitted and nonreadmitted patients were similar in age, body mass index, gender, comorbidities, indications for the index operation, and time to ostomy reversal. Readmitted patients had longer operative times (p = 0.002) and length of stay (p = 0.001), more intraoperative blood loss (p = 0.003), intraoperative complications (p = 0.005), ICU requirements (p < 0.0001), need for temporary nursing at discharge (p < 0.001), and higher total hospital costs than nonreadmitted patients (p = 0.0162). Longer operative time [odds ratio (OR) 1.006, 95 % confidence interval (CI) 1.001-1.012], intraoperative complications (OR 7.334, 95 % CI 1.23-43.761), ICU stay (OR 1.291, 95 % CI 1.18-1.893), delayed discharge (OR 1.085, 95 % CI 1.003-1.173), and discharge to skilled nursing facility (OR 6.936, 95 % CI 1.531-31.332) were independent predictors of readmission. Ostomy type had no independent effect on readmission., Conclusions: Differences in perioperative and outcomes variables exist between readmitted and nonreadmitted patients after ostomy reversal. Longer operative times, intraoperative complications, intensive care unit care, longer length of stay, and skilled nursing at discharge were independently predictive of readmission. These findings can be used to identify high-risk patients prospectively, potentially improving clinical outcomes and healthcare utilization.

Background: To evaluate readmissions to determine predictors and patterns of readmission., Methods: Prospective database review identified readmitted and non-readmitted patients after colorectal surgery. Variables for the index and readmission episode were examined., Results: A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older (P = .003), had more comorbidities (P < .0001), longer operative times (P < .0001), length of stay (P < .0001), and higher costs (P = .002). At the time of discharge, more readmitted patients required temporary nursing (P < .0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time (P = .05) and LOS were longer (P = .028), and more patients required temporary nursing care at the time of discharge (P = .046). Readmissions caused an additional mean hospital cost of $12,670.89., Conclusions: Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Despite laparoscopy and enhanced recovery pathways, some patients do not attain early discharge. Frailty is generally accepted as a marker of increased risk, complications, and mortality. Frailty may have the potential to identify patient outcomes., Purpose: The aim of this study was to evaluate frailty as a predictor of patients who might fail early discharge., Setting: This study was conducted at a tertiary referral center., Design: This was a case-matched study., Patients: Elective abdominal laparoscopic colorectal cases from 2009 to 2012 were selected., Methods: Review of a prospective database matched all cases with a postoperative day of discharge of ≤3 days to a >3 day of discharge cohort. All patients followed a standardized enhanced recovery pathway., Statistical Analysis: Categorical and ordinal variables were analyzed with the Student t test or Fisher exact test, and correspondence analysis evaluated the relationship between length of stay and the Modified Frailty Index., Main Outcome Measure: The primary outcome measure was the relationship between length of stay and the Modified Frailty Index., Results: There were 464 ≤3 day and 388 >3 day patients. The groups were similar in demographics and comorbidities. There were significant differences in the Modified Frailty Index (p < 0.01), operative time (p < 0.01), postoperative complications (p < 0.01), 30-day readmissions (p = 0.03), and 30-day reoperation rate (p < 0.01). Significantly more patients were discharged home in the ≤3 day cohort. Correspondence analysis demonstrated a higher Modified Frailty Index was indicative of longer length of stay. A Modified Frailty Index of 0 was strongly related to a length of stay 0 to 3 days, and a Modified Frailty Index of 2 was strongly related to a 8- to 14-day stay., Limitations: This was a single-center study performed on a retrospective data set., Conclusions: Patients undergoing elective colorectal surgery with a higher Modified Frailty Index were more likely not to attain early discharge. Despite similar demographics, the Modified Frailty Index could discriminate between patient outcomes, and correlated with longer operating times, length of stay, and readmissions. By using a prospective score to identify patients at risk for not achieving early discharge preoperatively, resources and postoperative support can be better allocated.

Background: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use., Objective: The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes., Design: This was a case-matched study., Methods: After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex., Settings: This study was performed at a tertiary referral center., Patients: Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included., Main Outcome Measures: The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway., Results: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen., Limitations: The single-surgeon, single-institution design was a limitation of this study., Conclusions: The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

This video demonstrates a laparoscopic abdominal perineal resection for a fixed 4.8-cm mass involving the posterior and left rectal walls and left puborectalis, 2 cm from the anal verge (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A127). We detail the steps of the procedure, all completed in lithotomy, including lateral-to-medial dissection; identification and protection of the left ureter and presacral nerves; division of the inferior mesenteric artery; medial-to-lateral dissection, with meeting the previous dissection plane; total mesorectal excision and pelvic dissection; perineal dissection and layered closure; and abdominal inspection and colostomy creation. Total operative time was 181 minutes. The specimen total mesorectal excision was complete with a negative circumferential radial margin (greater than 1 cm). Final pathology was T3N2M0.

Background: During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery., Methods: A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups., Results: A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery., Conclusions: RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.

Background: There is no standard for reporting rectal cancer distances from the distal resection margin in the literature. The objective was to demonstrate the importance of rectal cancer measurement from a standardized point., Methods: Review of databases at two international institutions identified 50 patients with rectal adenocarcinoma within 15 cm of the anal verge (AV), who had preoperative magnetic resonance imaging (MRI) and underwent surgery with curative intent. Expert radiologists reviewed the magnetic resonance images for anatomical distances from the anorectal ring (ARR) to the AV, from the ARR to the dentate line (DL), and from the DL to the AV. Anatomical measurements were compared with preoperative measurements to assess reporting inconsistencies., Results: Fifty patients with rectal adenocarcinoma were included in the study. The mean(s.d.) anatomical distance was 1.66(0.61) cm from the ARR to the DL, 3.78(0.61) cm from the ARR to the AV (maximum 5.5 cm) and 2.11(0.10) cm from the DL to the AV. The mean radiological distance from the distal tumour was 2.90(1.60) (median 3.2, range 0-7.5) cm to the ARR, 4.36(3.20) (median 4.2, range -0.5 to 12.8) cm to the DL and 6.13(3.39) (median 6.0, range 0-14.1) cm to the AV. There was a significant difference in the distal tumour margin between measurements made by the expert radiologists and reported preoperative measurements (P < 0.001). Significant differences were also found between the expert radiologists' MRI and rigid proctoscopic measurements (P = 0.025)., Conclusion: There was up to 5.5 cm variation, depending on which landmark was chosen for reporting the distal margin of rectal cancer. This has potential implications for surgical planning, interpreting radiological images and comparative studies., (© 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.)

Background: Despite using laparoscopy and enhanced recovery pathways (ERP), some patients are not ready for early discharge. The goal of this study was to identify predictors for patients who might fail early discharge, so that any defined factors might be addressed and optimized., Methods: A prospectively maintained database was reviewed for major elective laparoscopic colorectal surgical procedures. Cases were divided into day of discharge groups: ≤ 3 days and >4 days. All followed a standardized ERP. Demographic and clinical data were compared using Student's paired t tests or Fisher's exact test, with p value < 0.05 statistically significant. Regression analysis was performed to identify significant variables., Results: There were 275 ≤ 3 days patients and 273 >4 days patients. There were significant differences between groups in body mass index (p = 0.0123), comorbidities (p = 0.0062), ASA class (p = 0.0014), operation time (p < 0.001), postoperative complications (p < 0.001), and 30-day reoperation rate (p = 0.0004). There were no significant differences for intraoperative complications (p = 0.724), readmissions (p = 0.187), or mortality rate (p = 1.00). Significantly more patients were discharged directly home in the ≤ 3-days cohort. Using logistic regression, every hour of operating time increased the risk of length of stay >4 days by 2.35 %., Conclusions: Elective colorectal surgery patients with longer operation times and more comorbidities are more likely to fail early discharge. These patients should have different expectations of the ERP, as an expected 1- to 3-day stay may not be achievable. By identifying patients at risk for failing early discharge, resources and postoperative support can be better allocated and patients better informed about likely recovery.

Background: There has been a rapid increase in robotic colorectal surgery. Benefits of this technology are unclear and being investigated. However, differences in outcomes between centers have not been evaluated. Our aim was to evaluate outcomes for robotic colorectal procedures by surgeon and hospital volume., Study Design: A national inpatient database was reviewed for robotic colorectal resections performed during an 18-month period. Hospitals and surgeons were stratified into high, average, and low case volumes based on a normal distribution scale. High, average, and low volume was defined as ≤ 10, 11 to 20, and >20, respectively, for hospitals, and ≤ 5, 6 to 15, and >15, respectively, for surgeons. Short-term outcomes and hospital cost were evaluated., Results: There were 1,428 robotic colorectal cases across 123 hospitals and 411 surgeons evaluated. Only 13% (n = 16) of hospitals and 4.4% (n = 18) of surgeons performed a high volume of robotic colorectal cases. Lower volume was associated with significantly more overall complications (p < 0.001; p < 0.001), longer length of stay (p = 0.005; p < 0.001), and higher cost (p < 0.001; p < 0.001) at the hospital and surgeon level, respectively. High-volume hospitals and surgeons had significantly lower rates of postoperative bleeding (p < 0.001; p < 0.001) and ileus (p = 0.003; p = 0.0014)., Conclusions: Lower-volume providers, who are performing the majority of procedures, are generating more complications, longer hospital lengths of stay, and higher costs of care. These results have a negative impact on quality outcomes measures for those facilities. Although surgeons and hospitals continue to selectively explore robotics, this should be limited to high volume and interested surgeons and hospitals to offer high-quality outcomes to patients., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy. Our hypothesis was that elderly patients managed with laparoscopic colorectal surgery and an enhanced recovery protocol (ERP) can realize the same benefits of lower hospital length of stay (LOS) without increasing hospital costs or readmission rates., Methods: Review of a prospective database identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012. Patients were stratified into elderly (≥70 years old) and nonelderly (<70 years old) cohorts. The main outcome measures were discharge disposition, hospital costs, hospital LOS, and 30-day readmission rates between the laparoscopic and open groups., Results: A total of 302 nonelderly (66%) and 153 elderly (34%) patients were included in the analysis. The elderly cohort had significantly higher comorbidities than the nonelderly group. There were no mortalities. Operative variables (procedure time, blood loss, and intraoperative complications) were similar. At discharge, significantly more elderly patients required temporary nursing or home care. There were no significant differences in short-term outcomes of LOS, 30-day readmission rates, or costs for the episode of care between the two groups., Conclusions: Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients. Despite higher comorbidities, elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates.

Background and Objective: Our goal was to evaluate the different subtypes of mucosal melanoma and describe specific variables that predict outcomes., Methods: Prospective review of two tertiary care center databases identified 76 mucosal melanoma patients; 73 with complete records were included. Demographic and clinical data were analyzed. Cox regression determined variables impacting recurrence and survival., Results: In the 73 patients, the mean age was 64 years, and 74% were female. Sixty-seven percent presented with lymph node involvement, and 73% had ulcerated tumors. Major sites affected were nasal/palate/oral (36%), vulvar/vaginal/cervical (48%), and anorectal (15%). Mean overall and disease-free survival were 56.9 and 27.2 months. Variables associated with decreased survival included: lymphovascular invasion (HR17.70, P = 0.0093), Caucasian race (HR3.02, P = 0.0362), nasal/palate/oral sub-group (HR1.85, P = 0.026), Breslow thickness (HR1.23, P = 0.00004), T stage (HR1.34, P = 0.0075), M stage (HR3.03, P = 0.0039), and chemotherapy (HR3.13, P = 0.0002). The worst prognosis was seen in the nasal/palate/oral sub-group, with a median overall survival of 9.7 months and recurrence-free time of 4.5 months. This subtype also demonstrated high lymph node positivity, ulceration, and larger tumor size., Conclusion: The nasal, palate, oral subtype has the worst prognosis compared to other mucosal melanoma locations. Studies are ongoing to evaluate pathologic and genomic variables that may predict outcomes., (© 2013 Wiley Periodicals, Inc.)

Background: Natural orifice translumenal endoscopic surgery (NOTES) is a technique that uses transvisceral access to perform surgical procedures entirely through a natural orifice. Despite the increasing awareness of NOTES, there remain obstacles to its technical feasibility and widespread acceptance. Furthermore, with the paucity of high-level supporting evidence, NOTES currently remains an experimental technique., Objective: This article reviews the goals, applications, technical and practical challenges, and future direction of NOTES in gastrointestinal surgery.

Purpose: Several methods have been used to measure quality of life (QOL) in colorectal patients, but existing QOL assessment tools are often complex, require complicated analysis, lack specificity for colorectal surgery, and are not focused on assessment of perioperative care. The postoperative QOL (PQL) assessment is designed to capture subtle yet important QOL factors in an easy tool validated for the postoperative period. Although internally validated, PQL lacks external validation with a universally accepted QOL metric, such as the Rand Short Form-36 (SF-36). The purpose of this study was to externally validate the PQL metric to the SF-36 for colorectal surgery., Methods: The PQL was designed using 14 questions ranked on a Likert scale (1-10) with surgeon and patient input. After obtaining institutional review board approval, 100 consecutive colorectal surgery patients at University Hospitals, Case Medical Center were administered baseline and postoperative (2, 4, 8, 12, 30, 60, and 90 days) PQL and SF-36 questionnaires prospectively. Patients undergoing colorectal surgery via an abdominal approach (laparoscopic or open) for benign or malignant disease were included. Factor analysis and Spearman's rank test were performed between each of the 8 SF-36 scales and the 14 PQL questions and summary score. Convergent validity was demonstrated using Spearman's correlation coefficient at the domain and scale levels. The degree of agreement between PQL and SF-36 was assessed through Bland-Altman plots. Pairwise comparisons were made to determine any significant differences between the 2 scales., Results: Eighty-eight patients met all inclusion criteria and had a complete dataset, and were included in the analysis. SF-36 factor analysis confirmed comparability between the study group and the general population. All PQL items correlated with all 8 mental and physical health domains in the SF-36 (P < .0001). Bland-Altman plots demonstrated consistently similar measure for level of agreement between PQL and SF-36 as indicated by the 95% limits of agreement., Conclusion: The PQL and SF-36 demonstrated a strong and consistent level of agreement across all 8 domains for pre- and postoperative scores in colorectal surgery patients. PQL is constructually valid in the perioperative period. Based on our analysis, the novel PQL metric represents a simple, point-of-care alternative to SF-36 for rapid QOL assessment, and validates use of the PQL metric in abdominal surgery., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: This study was designed to evaluate the feasibility of AlloMEM™, a novel lyophililzed human peritoneal membrane, at peritoneal reconstitution, and decreasing adhesion formation after temporary loop ileostomy., Methods: In a pilot study, ten patients had AlloMEM™ used during elective formation of a temporary diverting loop ileostomy for benign or malignant colorectal disease. A blinded investigator and the operating surgeon analyzed the change in adhesion formation and peritoneal remodelling using ileostomy mobilization time and a 5-point adhesion scale grading intra-abdominally and at the subcutaneous and fascial levels., Results: The mean body mass index was 31 [standard deviation (SD) 5.6], and 40 % of patients had previous abdominal surgery. Ileostomies were reversed after a mean 14 weeks (SD 6.0). The mean ileostomy mobilization time was 27.2 min (SD 12.0). From baseline to ileostomy reversal, there were significant increases in adhesions at the subcutaneous (p = 0.0002) and fascial levels (p = 0.0024). The increased subcutaneous adhesions were associated with improved peritoneal remodeling. There was no significant increase in adhesions from baseline to ileostomy reversal at the intra-abdominal points (p = 0.9393) or around the ileostomy site (p = 0.6128). The median hospital length of stay was 2.6 days (range, 2-3). A single adverse event related to product packaging led to redesign of the packaging process., Conclusions: Use of AlloMEM™ in ileostomy closures suggested improvement in adhesions around the fascia and promotion of peritoneal remodeling. AlloMEM™ was safe, feasible, and easy to use in this pilot study. Comparative research is needed to assess the outcomes with this novel product.

Unlabelled: The aim of the study was to evaluate the cost of surgical care and short-term outcomes of Crohn's disease(CD) in the era of laparoscopy and biologic therapy., Material and Methods: Review of a prospective database identified CD patients that underwent surgical management. Patients were stratified into laparoscopic, open, and converted approaches. Main outcome measures were short-term patient outcomes and cost of care by approach., Results: 92 patients were analyzed- 63.1% laparoscopic, 32.6% open, 4.3% converted. The majority was elective (100% converted, 94.8% laparoscopic, 90% open) and segmental resections (75% converted, 70.7% laparoscopic, 43.3% open). Operative times were similar between laparoscopic and open (152 minutes and 138 minutes, respectively). More open patients required ICU care (20% versus 12.1% laparoscopic and 0% converted). The median LOS was 3 (1-25) days laparoscopic, 4 (1-29) open and 4 (3-8) converted. The laparoscopic complication rate was 15.5%, readmission rate 12.1%, and reoperation rate 8.6%. The mean total hospital cost was $9,702 laparoscopic, $10,782 open, and $13,293 for converted cases (US Dollars)., Conclusions: Laparoscopy is appropriate for most CD cases. When necessary to combine with open surgery, this results in efficient and effective patient outcomes and healthcare utilization. These results are important when weighing the cost of ongoing medical therapy versus surgical intervention.

Tanezumab is a humanized monoclonal antibody that specifically inhibits nerve growth factor as a treatment for chronic pain. This phase IIB study investigated the efficacy and safety of tanezumab for chronic low back pain vs placebo and naproxen. Patients (N=1347) received intravenous tanezumab (5, 10, or 20mg every 8weeks), naproxen (500mg twice daily), or placebo. The primary efficacy end point was mean change in daily average low back pain intensity (LBPI) from baseline to week 16. Secondary end points included mean change from baseline to week 16 in the Roland Morris Disability Questionnaire and Patient's Global Assessment (PGA) of low back pain. Tanezumab 10 and 20mg had similar efficacy profiles and significantly improved LBPI, Roland Morris Disability Questionnaire, and PGA scores vs both placebo and naproxen (P⩽.05). Tanezumab 5mg provided improvement of PGA scores vs placebo (P⩽.05), and naproxen resulted in significant improvement of LBPI vs placebo (P⩽.05). Adverse event incidence was comparable across tanezumab doses but higher than with placebo or naproxen. Arthralgia, pain in extremity, headache, and paresthesia were the most commonly reported adverse events by tanezumab-treated patients. The most frequently reported adverse events resulting in discontinuation of tanezumab treatment were arthralgia and paresthesia; the highest frequency was observed with tanezumab 20mg (both 1.4%). Serious adverse event incidence was similar across treatments. In conclusion, tanezumab provided significantly greater improvement in pain, function, and global scores vs placebo and naproxen in patients with chronic low back pain., (Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Gastric electric stimulation (GES) is used for refractory gastroparesis symptoms. Although symptomatic improvement has been reported with GES, few studies describe the need for additional surgery after placement. Our goal was to evaluate the outcomes of a large series of GES at a single institution., Methods: A retrospective review was performed for patients undergoing Enterra GES (Medtronic, Inc.) placement for refractory gastroparesis from October 2000 to October 2011. The main outcome measures were the need/indications for additional procedures and symptom improvement., Results: A total of 266 patients had a GES implanted; 233 had complete records and were included in the analysis. Fifty-eight percent (n = 135) required an additional procedure after GES placement. Nutrition access (45 patients requiring 77 procedures) and subcutaneous pocket issues (n = 21) were the most common indications for subsequent procedures. Twelve percent (n = 29) had the GES explanted, mainly for continued gastroparetic symptoms (n = 11), mechanical issues (n = 9), or infection (n = 4). Ninety patients had subsequent hospitalizations, mainly for gastroparetic flares. Mortality during the follow-up period was 2.1 %. BMI was predictive of additional surgical procedure: when overweight, the risk of pocket revision increased 4.45 times (OR = 4.452). Of 74 most recent patients with prospective long-term outcome data, 70 % reported improved symptoms of pain, bloating, and nausea., Conclusions: Although most patients reported symptomatic improvement after GES implantation, there is often a need for additional surgical procedures as well as associated complications after GES placement. Additional procedures were most frequent for surgical nutrition and subcutaneous pocket issues; pocket revisions were more frequent in obese patients. From our results, we amended our practice to add a jejunostomy tube in malnourished patients and suture the stimulator to the subcutaneous pocket fascia. Further studies will determine if these changes reduce the rate of complications and additional procedures after GES placement.

Unlabelled: Hospital length of stay (LOS) and readmissions continue to be expensive and unexpected events following colorectal surgery (CRS) whether patients follow enhanced recovery pathways or traditional care. Predictors of these adverse events could facilitate identification and optimization of CRS patients., The Aim of the Study: To examine the impact of white blood cell count (WBC) and C-reactive protein (CRP) levels as predictors of delayed recovery or hospital readmission following CRS., Material and Methods: Patients undergoing laparoscopic or open abdominal colorectal surgery by a single surgeon were managed using standardized enhanced recovery pathways. Those with postoperative day 2 CRP and white blood cell values were evaluated. Outcomes included 30-day hospital readmission rates and postoperative length of hospital stay., Results: CRP values were available for 193 patients (86 Male, mean age 58.6 years). Ninety-nine patients had surgery for colon cancer, 23 for Crohn's disease, 19 for ulcerative colitis, 31 for diverticulitis and 18 for other reasons. Twenty patients (10.4%) were readmitted to the hospital within 30 days of surgery. POD2 CRP accurately predicted short length of hospital stay (p< 0.01). Average CRP was 6.3 in the LOS of < 3 days or less, and 11.7 in patients with LOS >4 days. The mean CRP of the readmission and non-readmission groups was 11.8 and 9.9, respectively (p=0.29). The average POD 2 WBC of the readmission and non-readmission groups was 10.6 and 9 respectively (p=0.01)., Conclusion: A low POD2 CRP level was correlated with a shorter LOS, but it did not predict readmission. Conversely, POD2 WBC, and the difference in WBC from baseline were associated with readmission. These markers may be useful indicators to predict suitability of early discharge in an ERP. Further evaluation in prospective trials is warranted.

Background: Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates., Study Design: A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group., Results: Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively., Conclusions: Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)