Search

Little is known about the long-term functional outcomes of restorative proctocolectomy.The aim of this study was to examine ileoanal pouch outcomes 20 and 30 years postoperatively.This is a retrospective case series.This study was conducted at a tertiary care referral center.Patients who underwent restorative proctocolectomy between 1980 and 1994 were identified. Those with ≥20 years of in-person follow-up were included.Pouch function, pouchitis, anal stricture, and pouch failure rates were analyzed.A total of 203 patients had ≥20 years of follow-up. Of those, 71 had ≥30 years of follow-up. Initial diagnoses included ulcerative colitis (83%), indeterminate colitis (9%), familial adenomatous polyposis (4%), and Crohn's disease (3%). Twenty-one percent of those with ulcerative or indeterminate colitis later transitioned to Crohn's disease. Mean daily stool frequency was 7 (IQR 6-8), 38% experienced seepage, 31% had anal stenosis, 47% experienced pouchitis, and 18% had pouch failure. Over time, stool frequency increased in 41% of patients, stayed the same in 43%, and decreased in 16%. Patients older than 50 years at the time of construction had more daily bowel movements (median 8 vs 6; p = 0.02) and more seepage (77% vs 35%; p = 0.005) than those younger than 50 years. Patients with Crohn's disease had higher stool frequency (median 8 vs 6; p0.001) and higher rates of anal stenosis (44% vs 26%; p = 0.02), pouchitis (70% vs 40%; p0.001), and pouch failure (38% vs 12%; p0.001) compared to non-Crohn's patients. Patients with ≥30 years of follow-up had similar function as those with 20-30 years of follow-up.This was a retrospective, single-institution study. Only 35% of pouches created during the study period had20 years of follow-up.Most patients maintain reasonably good function and retain their pouches after 20 years. Over time, stool frequency and seepage increase. Older age and Crohn's disease are associated with worse outcomes. See Video Abstract at http://links.lww.com/DCR/B801.ANTECEDENTES:se sabe poco sobre los resultados funcionales a largo plazo de la proctocolectomía restauradora.OBJETIVO:El objetivo de este estudio fue examinar los resultados del reservorio ileoanal 20 y 30 años después de la operación.DISEÑO:Serie de casos retrospectiva.ENTORNO CLÍNICO:Centro de referencia de atención terciariaPACIENTES:Se identificaron pacientes que se sometieron a proctocolectomía restauradora entre 1980 y 1994. Se incluyeron aquellos con ≥20 años de seguimiento en persona.PRINCIPALES MEDIDAS DE VALORACIÓN:Se analizaron la función, inflamación, tasas de falla del reservorio y estenosis anal.RESULTADOS:Un total de 203 pacientes tuvieron ≥20 años de seguimiento. De ellos, 71 tenían ≥30 años de seguimiento. Los diagnósticos iniciales incluyeron colitis ulcerosa (83%), colitis indeterminada (9%), poliposis adenomatosa familiar (4%) y enfermedad de Crohn (3%). El 21% de las personas con colitis ulcerosa o indeterminada pasaron posteriormente a la enfermedad de Crohn. La frecuencia promedio de las deposiciones diarias fue de 7 (rango intercuartil 6-8), el 38% experimentó filtración, el 31% tuvo estenosis anal, el 47% experimentó pouchitis y el 18% tuvo falla del reservorio. Con el tiempo, la frecuencia de las deposiciones aumentó en el 41% de los pacientes, se mantuvo igual en el 43% y disminuyó en el 16%. Los pacientes mayores de 50 años en el momento de la construcción tenían más evacuaciones intestinales diarias (media 8 vs 6, p = 0,02) y más filtraciones (77% vs 35%, p = 0,005) que los menores de 50 años. Los pacientes con enfermedad de Crohn tenían mayor frecuencia de deposiciones (media 8 vs 6, p0,001) y tasas más altas de estenosis anal (44% vs 26%, p = 0,02), inflamacion (70% vs 40%, p0,001) y falla del reservorio (38% frente a 12%, p0,001) en comparación con pacientes que tenian enfermedad de Crohn. Los pacientes con ≥30 años de seguimiento tuvieron una función similar a aquellos con 20-30 años de seguimiento.LIMITACIONES:Este fue un estudio retrospectivo de una sola institución. Solo el 35% de los reservorios creados durante el período de estudio tuvieron más de 20 años de seguimiento.CONCLUSIONES:La mayoría de los pacientes mantienen una función razonablemente buena y conservan el reservorio después de 20 años. Con el tiempo, la frecuencia de las deposiciones y la filtración aumentan. La vejez y la enfermedad de Crohn se asocian con peores resultados. Consulte Video Resumen en http://links.lww.com/DCR/B801. (Traducción - Dr. Ingrid Melo).

Objective To identify strategies and barriers to career progression in early-career colorectal surgeons. Design Qualitative research study performed via semi-structured interviews with early-career, board-certified colon, and rectal surgeons. Responses were analyzed, coded, and categorized to understand strategies towards career progression, perceived barriers to career progression, beliefs about case mix, and referral patterns. Setting Interviews conducted in person and via telephone across the United States and Canada. Participants Early-career board-certified colorectal surgeons Results Twenty-two board-certified colorectal surgeons currently employed in 14 states and 1 foreign country were interviewed. Fourty-five percent were female. Their current practice environment was described as academic (77%), private practice (18%), or military (5%). Seventy-seven percent of surgeons were satisfied with their career progression. Seventy-two percent were satisfied with the case volume. Seventy-two percent were satisfied with their case mix. When asked about strategies for career progression, surgeons made 77 comments focused on three main themes: optimization of their job search, optimization of relationships while on the job, and efforts to augment individual achievement. When asked about barriers to career advancement, surgeons most frequently commented on a lack of time and a lack of mentors. When asked about case mix, 63% of surgeons felt that they had no control over it. They were evenly divided between believing that a broad case mix or a niche specialized case mix was more instrumental for career progression. Conclusions Early-career colorectal surgeons were mostly satisfied with their career progression, volume, and case mix. In discussing their careers, many have developed a number of strategies focused on growth as an individual as well as relationship building. They also identified a number of barriers including lack of time and lack of mentorship. Early-career surgeons may be able to utilize these strategies and anticipate barriers prior to starting their first job, leading to greater likelihood of career satisfaction.

Background The Bundled Payments for Care Improvement initiative links payments for service beneficiaries during an episode of care (limited to 90 days from index surgery discharge). Objective The purpose of this study was to identify drivers of costs/payments for the major bowel Bundled Payments for Care Improvement initiative. Design Discharges from the Medicare Standard Analytic Files of hospitals participating in the major bowel bundle of the Bundled Payments for Care Improvement initiative were analyzed. Settings The study was conducted at 4 tertiary care centers. Patients All patients in diagnostic related groups of 329, 330, or 331 treated at eligible facilities between September 1, 2012, and September 30, 2014, were included. Main outcome measures We calculated all costs/payments for the bundled period, that is, 3 days before surgery, the index hospitalization including surgery, and the 90-day postoperative period. We then determined costs for laparoscopic versus open procedures using International Classification of Diseases, Ninth Revision, procedure codes for each of the diagnostic related groups, as well as in aggregate. Last, we calculated differential impact of cost drivers on overall total episode costs. Results In the cohort of hospitals participating in the major bowel Bundled Payments for Care Improvement initiative, open procedures ($45,073) cost 1.6 times more than laparoscopic. For the lowest complexity diagnostic related group (331), performance of the procedure with open techniques was the largest total episode cost driver, because use of postdischarge services remained low. In the highest complexity diagnostic related group (329), readmission costs, skilled nursing facilities costs, and home health services costs were the greatest cost drivers after hospital services. Limitations The analyses are limited by the retrospective nature of the study. Conclusions These results indicate that efforts to safely perform open procedures with laparoscopic techniques would be most effective in reducing costs for lower complexity diagnostic related groups, whereas efforts to impact readmission and postdischarge service use would be most impactful for the higher complexity diagnostic related groups. See Video Abstract at http://links.lww.com/DCR/B420. ?CUALES SON LOS FACTORES DETERMINANTES DE LOS COSTOS DE LA INICIATIVA DE MEJORA DE LA ATENCION DE PAGOS COMBINADOS PARA EL INTESTINO MAYOR?: La iniciativa de pagos combinados para la mejora de la atencion (BPCI) vincula los pagos para los beneficiarios del servicio durante un episodio de atencion (limitado a 90 dias desde el alta hospitalaria de la cirugia indice).Identificar los factores determinantes de los costos / pagos de la iniciativa BPCI intestinal mayor.Analisis de altas de los Archivos Analiticos Estandar de Medicare de los hospitales que participan en el paquete intestinal principal de la iniciativa BPCI.Todos los pacientes en Grupos Relacionados con el Diagnostico (GRD) de 329, 330 o 331 tratados en instalaciones elegibles desde el 1 de Septiembre de 2012 hasta el 30 de Septiembre de 2014.Calculamos todos los costos / pagos para el periodo combinado, es decir, tres dias antes de la cirugia, el indice de hospitalizacion incluida la cirugia y el periodo posoperatorio de 90 dias. Luego, determinamos los costos de los procedimientos laparoscopicos versus abiertos utilizando codigos de procedimiento ICD-9 para cada uno de los GRD, asi como en conjunto. Por ultimo, calculamos el impacto diferencial de los generadores de costos sobre los costos totales del episodio.En la cohorte de hospitales que participan en la iniciativa BPCI del intestino principal, los procedimientos abiertos ($ 45.073) cuestan 1,6 veces mas que los laparoscopicos. Para el GRD de menor complejidad (331), la realizacion del procedimiento con tecnicas abiertas fue el mayor factor de costo total del episodio, ya que la utilizacion de los servicios posteriores al alta se mantuvo baja. En el GRD de mayor complejidad (329), los costos de readmision, los costos de las instalaciones de enfermeria especializada y los costos de los servicios de salud en el hogar fueron los mayores factores de costo despues de los servicios hospitalarios.Los analisis estan limitados por la naturaleza retrospectiva del estudio.Estos resultados indican que los esfuerzos para realizar procedimientos abiertos de manera segura con tecnicas laparoscopicas serian mas efectivos para reducir los costos de los GRD de menor complejidad, mientras que los esfuerzos para impactar la readmision y la utilizacion del servicio posterior al alta serian mas impactantes para los GRD de mayor complejidad. See Video Abstract at http://links.lww.com/DCR/B420.

We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques. We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x2 and t tests and used the Bonferroni Correction to account for multiple statistical testing. From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p

Purpose To describe a community hospital pharmacy department’s novel approach to addressing safe use of fentanyl patches in acute and subacute care patients. Summary Beginning in 2017, improvement opportunities were identified within the medication-use process for fentanyl patches at Cleveland Clinic Euclid Hospital. Prescribing was addressed through development of a procedure requiring an opioid status verification by a pharmacist for all fentanyl patch orders. This procedure includes determination of indication, review of prior opioid use, and documentation within the medical record. At baseline in 2017, 11 of 45 fentanyl patches were initiated for acute pain. In the first year of the procedure, 1 of 13 orders was initiated for acute pain, and in the second year 2 of 24 orders for fentanyl patches were initiated for acute pain. With each review, the pharmacy department identified additional safety and clinical education opportunities. Subsequently, inventory and dispensing practices for patches were assessed. The hospital’s inventory was decreased and dispensing practices were altered to mitigate accessibility of the patches. This resulted in a decrease of 73.65% in the on-hand quantity from 2018 to 2020. The overall morphine milligram equivalents (MME) per 24 hours of this dosage form available in the hospital were reduced from 56,073.6 MME in 2018 to 13,557.6 MME in 2020 (75.82% decrease). Conclusion Evaluation of the fentanyl patch medication-use process and pharmacy-driven interventions resulted in an increase in appropriate utilization of fentanyl patches and a decrease in accessible MME of this potent dosage form.

With a recent emphasis on sterile compounding regulatory requirements, a newly constructed space or renovations to an existing space may need to be considered in any pharmacy where sterile compounding occurs. Pharmacy leaders from two facilities within a health system outline their experience with important aspects of cleanroom renovation learned through the process. Identifying how to maintain sterile compounding operations during construction is required to continue patient-care services. The collaboration of several disciplines on a construction team will help ensure the new/ renovated space has the necessary components to eventually support compounding sterile preparations. Through thorough understanding of the proposed changes of sterile compounding regulatory requirements and extensive planning, a successful renovation and go-live coordination can occur. This article serves to summarize key takeaways from two pharmacy leaders' cleanroom construction experiences.

Purpose The impact of a gravimetric-based technology-assisted workflow (TAWF) system on the nonhazardous compounded sterile product (CSP) error capture rate, production times, and pharmacy staff perceptions of compounding methods was evaluated. Methods For 2 weeks prior to TAWF implementation, staff used a punch clock to document production times with a volumetric method. Preimplementation error data were captured in a previous study; TAWF software captured error and time data in the postimplementation period. An online staff survey was administered before and 90 days after TAWF implementation to evaluate perceptions of the 2 methods. Results The error capture rates were 0.47% in the preimplementation period and 41.48% in the postimplementation period. The median time to prepare CSPs was significantly shorter in the preimplementation period versus the postimplementation period (p < 0.0001). The median time to check CSPs was significantly shorter at both 90 days (p < 0.0001) and 180 days (p = 0.0006) after TAWF implementation. When asked if the current method was the safest and the most accurate method for preparation, staff members’ perceptions improved from neutrality to agreement when the TAWF was implemented. Staff members were in agreement that the volumetric method was faster than the gravimetric TAWF method but were neutral as to whether the latter was the preferred compounding method. Conclusion The study results indicated that gravimetric-based TAWF preparation of nonhazardous CSPs is slower than manual volumetric preparation but can improve the error capture rate. Staff perceived the gravimetric TAWF method to be the safest and most accurate for producing CSPs.

OBJECTIVE Colorectal surgery (CRS) training has seen many changes over the years. This study sought to identify aspects of CRS residency curriculum that were most valued by recent graduates and what changes could be made to improve training. DESIGN Semistructured interviews were performed with board-certified colorectal surgeons 2 to 7years removed from their CRS residency. Interview responses were qualitatively analyzed and converted to coded, categorizable data. Subjects were recruited via a snowball sampling method. SETTING Interviews were conducted in person and via telephone with surgeons in a variety of practices across the United States and Canada. Analysis was performed by a team at Lahey Clinic, Burlington, MA, an academic, tertiary care center. PARTICIPANTS Board certified colorectal surgeons 2 to 7years removed from CRS residency. RESULTS Twenty surgeons from 11 different CRS residencies were interviewed. At the time of the interview, surgeons were employed in 13 states and 1 foreign country. When asked what aspects of their CRS residency were of value, surgeons produced 74 comments emphasizing: volume of cases (65% of subjects), variety of cases (55%), development of technical skills (40%), management of specific diseases (35%), faculty (30%), mentorship (30%), and practice management (15%). With regard to technical skills, surgeons cited pelvic surgery (40%) and minimally invasive techniques (45%) as the exposures that helped them become successful. When discussing what could be added to training, subjects made 54 comments identifying: more robotic exposure (35%), more anorectal disease (30%), more pelvic floor exposure (25%), and practice management/billing (35%) as items to incorporate. Sixty five percent of subjects believed that “nothing” should be eliminated from their training. CONCLUSIONS Young colon and rectal surgeons valued their training highly and strongly declined to eliminate any substantial part of the existing curriculum. They also expressed a strong desire to add more elements to the CRS residency including further robotic training, more anorectal, more pelvic floor, and further training in practice management.

In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.

Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission.This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection.This is a retrospective review of a prospectively compiled single-institution database.From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included.The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection.Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value.This study was limited by its retrospective design and because all patients were treated at a single center.Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.

Horseshoe fistula is a challenging benign anorectal condition to treat. The aim of this study was to assess the utilization and success of different definitive fistula repair techniques in the treatment of horseshoe fistula.This was a retrospective case series which included all patients who were treated for horseshoe fistula from 2006 to 2019 at a single, tertiary care center and whom had at least one follow-up visit. Patients were excluded if 18 years of age or carried a diagnosis of Crohn's disease. Patients were assessed for fistula recurrence and incontinence.Sixty-eight patients were identified. On average, they were 47 years old, 63% male, and 18% current smokers. Seventy-nine percent required seton during their treatment course. Of the 8 first attempts at fistula repair, the types of repair included flap (15%), LIFT (35%), fistulotomy (31%), plug (12%), and fistulotomy and immediate reconstruction (1%). Recurrence for these procedures was as follows: flap 30%, LIFT 21%, fistulotomy 14%, plug 88%, and fistulotomy and immediate reconstruction 0%. Twelve patients who recurred underwent 17 additional procedures to attempt to cure their fistula. Overall, of those who underwent any attempt at definitive repair, 82% of patients were cured of their fistula, 12% had a chronic seton, and 6% had a chronic fistula. Thirteen percent of those who were cured had incontinence. The mean follow-up time was 1.1 years. Patients required a median of 3 procedures (range 1-11).Horseshoe fistula remains a complex anorectal condition. Successful repair can be performed in 80% of patients. However, repair can often require multiple surgical procedures.

The objective of this study was to describe the response by state boards of pharmacy pertaining to personal protective equipment shortages during the early phase of the COVID-19 pandemic. All webpages of state boards of pharmacy were independently reviewed for written guidance pertaining to personal protective equipment conservation strategies in sterile compounding and deviations from United States Pharmacopeia General Chapter797standards; each guidance was then reviewed for referenced sources. Of 52 state pharmacy regulatory bodies, 38 (73.08%) provided guidance to modifying personal protective equipment use during sterile compounding activities to mitigate supply shortages. The references for each guidance varied, however, most referenced CriticalPoint, LLC or the United States Pharmacopeia. A few of the guidance documents from boards also permitted other deviations from United States Pharmacopeia Chapter797standards. Early in the pandemic, pharmacists within sterile compounding practices had to conserve personal protective equipment while mitigating contamination risk. Pharmacists looked to state boards of pharmacy for guidance. This report shows a high level of state response to the personal protective equipment shortage induced by the pandemic.

PURPOSE The impact of a gravimetric-based technology-assisted workflow (TAWF) system on hazardous compounded sterile product (CSP) production time, staff perception of safety, and job satisfaction was evaluated. METHODS For 2 weeks before implementation of a gravimetric-based TAWF, staff utilized an automated punch clock to document the time to prepare and check CSPs compounded volumetrically. Simultaneously, an anonymous, online survey was e-mailed to staff to evaluate their perceptions regarding the safety of volumetric preparation and satisfaction with their role preparing CSPs. At 30 and 90 days postimplementation of the TAWF, staff completed identical follow-up surveys to evaluate safety and satisfaction using the gravimetric-based TAWF. The TAWF software captured product preparation and check times postimplementation. Data regarding the accuracy of compounding were collected postimplementation and compared to accuracy data available in the published literature. RESULTS The median time to prepare CSPs preimplementation (n = 643) was 445 seconds versus 359 seconds (n = 728) 90 days after implementation of the gravimetric-based TAWF (p < 0.001). The median time to review and check CSPs was 45 seconds before implementation and 19 seconds 90 days after implementation (p < 0.01). Survey respondents preferred to use the TAWF to compound CSPs over volumetric preparation. There was no difference in respondents' perception of safety and accuracy of the TAWF preimplementation versus postimplementation. CONCLUSION The gravimetric-based TAWF preparation of hazardous CSPs was faster and more accurate than manual volumetric preparation and improved staff perception regarding the accuracy of the CSP preparation process.

Purpose One academic medical center’s efforts to move toward compliance with requirements of United States Pharmacopeia ( USP ) chapter 800 through a multidepartmental collaborative initiative are described. Summary Requirements of USP general chapter 800 (enforceable as of December 2019) address the handling of hazardous drugs (HDs) throughout the entire operational and clinical cycle, from receiving to compounding, administration, and waste disposal. Due to the variety of pharmacy operational areas in which HDs are encountered at University of North Carolina Medical Center (UNCMC), multiple pharmacy managers oversee the safe handling of HDs. To determine baseline compliance with USP chapter 800 requirements, a common assessment tool was developed to ensure a standardized approach to compliance assessment in all areas. An interdepartmental workgroup was created to ensure institutionwide support for a collaborative compliance initiative, a uniform understanding of compliance risks, and robust action planning. UNCMC has taken a number of steps toward USP chapter compliance in areas such as engineering controls, environmental quality and controls, use of personal protective equipment, hazard communication programs, personnel training, spill control, and medical surveillance. Conclusion Achieving USP chapter 800 compliance presented several operational, clinical, and financial challenges for the medical center, requiring months of preparation and diligence by the hospital leadership. The pharmacy department–led compliance collaborative allowed departments to proactively align while implementing practice and quality standards to foster safety for patients, workers, and the environment.

We propose that prolonged colorectal surgery operative times are associated with increased 30-day adverse events. We identified a cohort from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 2005 through December 2012. Patients who underwent colectomy with primary anastomosis were selected using CPT codes. Operative time was categorized into short, average, and long based on mean operative times 61 SD. NSQIP-approved multivariate models were used to identify associations between operative time and 30-day adverse events. A total of 113,615 patients underwent colorectal resection of which 46 per cent were laparoscopic and 12 per cent were identified as long operative times. Patients with long operative procedures had 34 per cent more superficial surgical site infections, 65 per cent more organ space infections, 69 per cent more abdominal dehiscences, 44 per cent more thrombotic complications, 45 per cent more urinary tract infections, 40 per cent more returns to the operating room, and 36 per cent more prolonged lengths of stay ( P < 0.05 for all analyses). The multivariable analysis revealed an association between long operative times and increased adverse events despite adjustment for all NSQIP recommended covariates. Our results reveal increased 30-day adverse events with increased operative time. We propose that operative time may serve as a proxy for surgical complexity in colorectal surgery.

BACKGROUND: Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States. OBJECTIVE: We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias. DESIGN: This was a prospective observational study. SETTING: The study occurred at the 2017 Tripartite Meeting. MAIN OUTCOME MEASURES: The percentage of women in the formal program relative to conference attendees and forms of address. METHODS: Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender. RESULTS: Of physicians and medical students, 32% (n=484) of the 1,532 attendees were women. Women comprised 28% of moderators (n=26) and 28% of speakers (n=80). The highest percentage of women moderators and speakers was in education (48%) and the lowest in techniques and technology (17%). In the 4¼7 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs. 54.0%, p=0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs. 66.7%, p=0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs. 59.2%, p=0.003). LIMITATIONS: Yearly program gender composition may fluctuate. Low numbers in certain areas limits interpretability. Other factors potentially influenced speaker introductions. CONCLUSIONS: Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.

BACKGROUND Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. OBJECTIVE The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. DESIGN This was a retrospective analysis of prospectively collected departmental data with 100% capture. SETTINGS The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. PATIENTS A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. MAIN OUTCOME MEASURES Clinical anastomotic leak within 30 days of surgery was measured. RESULTS Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). LIMITATIONS This was a retrospective study with limited data to perform a multivariate analysis. CONCLUSIONS Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.

Treatment of left-sided colorectal anastomotic leaks often requires fecal stream diversion for prevention of further septic complications. To manage anastomotic leak, it is unclear if diverting ileostomy provides similar outcomes to Hartmann resection with colostomy. We identified all patients who developed anastomotic leak following left-sided colorectal resections from 1/2012 through 12/2014 using the American College of Surgeons National Surgical Quality Improvement Program. Then, we examined the risk of mortality and abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection. There were 1745 patients who experienced an anastomotic leak in a cohort of 63,748 patients (3.7%). Two hundred thirty-five patients had a reoperation for anastomotic leak involving the formation of a diverting ileostomy (n = 77) or Hartmann resection (n = 158). There was no difference in mortality or abdominal reoperation in patients treated with diverting ileostomy (3.9, 7.8%) versus Hartmann resection (3.8, 6.3%) (p = 0.8). There was no difference in the outcomes of mortality or need for second abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection for left-sided colorectal anastomotic leak. Thus, select patients with left-sided colorectal anastomotic leaks may be safely managed with diverting ileostomy.

The impact of process improvement through surgeon feedback on outcomes is unclear.We sought to evaluate the effect of biannual surgeon-specific feedback on outcomes and adherence to departmental and Surgical Care Improvement Project process measures on colorectal surgery outcomes.This was a retrospective analysis of prospectively collected 100% capture surgical quality improvement data.This study was conducted at the department of colorectal surgery at a tertiary care teaching hospital from January 2008 through December 2013.Each surgeon was provided with biannual feedback on process adherence and surgeon-specific outcomes of urinary tract infection, deep vein thrombosis, surgical site infection, anastomotic leak, 30-day readmission, reoperation, and mortality. We recorded adherence to Surgical Care Improvement Project process measures and departmentally implemented measures (ie, anastomotic leak testing) as well as surgeon-specific outcomes.We abstracted 7975 operations. There was no difference in demographics, laparoscopy, or blood loss. Adherence to catheter removal increased from 73% to 100% (p0.0001), whereas urinary tract infection decreased 52% (p0.01). Adherence to thromboprophylaxis administration remained unchanged as did the deep vein thrombosis rate (p = not significant). Adherence to preoperative antibiotic administration increased from 72% to 100% (p0.0001), whereas surgical site infection did not change (7.6%-6.6%; p = 0.3). There were 2589 operative encounters with anastomoses. For right-sided anastomoses, the proportion of handsewn anastomoses declined from 19% to 1.5% (p0.001). For left-sided anastomoses, without diversion, anastomotic leak testing adherence increased from 88% to 95% (p0.01). Overall leak rate decreased from 5.2% to 2.9% (p0.05).Concurrent process changes make isolation of the impact from individual process improvement changes challenging.Nearly complete adherence to process measures for deep vein thrombosis and surgical site infection did not lead to measureable outcomes improvement. Process measure adherence was associated with decreased rate of anastomotic leak and urinary tract infection. Biannual surgeon-specific feedback of outcomes was associated with improved process measure adherence and improvement in surgical quality.

In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.

We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques.We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with xFrom a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups.Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

Diverticulitis is a common problem resulting in more than 300,000 hospital admissions in the United States each year. Approximately 1% to 4% of patients with diverticulosis develop diverticulitis, and approximately one-third of colectomies and colostomies in the United States are performed for diverticular disease. The clinical presentation varies from mild abdominal pain to generalized peritonitis. The chapter updates our current recommendations and changing guidelines for this common disease.

The aim of this article is to evaluate geographic variation in the incidence of diverticulitis and examine behavioral and environmental factors associated with high rates of diverticulitis across the United States. We used state hospital discharge data from 20 states to determine rates of inpatient diverticulitis from January 2002 to December 2004 at patient's county of residence. Next, we merged the county level data with behavioral and environmental survey data from the Behavioral Risk Factor Surveillance System (BRFSS). Finally, we determined the association between behavioral and environmental factors (i.e., teeth removal, dental cleaning, air quality, smoking, alcohol, vaccine, vitamins, and mental health) and high rates of diverticulitis. From January 1, 2002, to December 31, 2004, a total of 345,216 hospitalizations for acute diverticulitis were recorded for 1,055 counties. We identified rates of diverticulitis that ranged from 35.4 to 332.7 per 100,000 population. On univariate analysis, high diverticulitis burden was associated with regions of the country with substantial tooth loss from dental disease (45.8% for high diverticulitis counties vs. 37.5% for low diverticulitis counties; p = 0.0001). There is considerable variability in diverticulitis cases by county of residence across the nation. Potential triggers of diverticulitis may be associated with tooth removal and sun exposure.

The aim of this study was to determine whether there is an association between appendicitis and diverticulitis.This study is a retrospective cohort analysis.This study was conducted in a subspecialty practice at a tertiary care facility.We examined the rate of appendectomy among 4 cohorts of patients: 1) patients with incidentally identified diverticulosis on screening colonoscopy, 2) inpatients with medically treated diverticulitis, 3) patients who underwent left-sided colectomy for diverticulitis, and 4) patients who underwent colectomy for left-sided colorectal cancer.There were no interventions.The primary outcome measured was the appendectomy rate.We studied a total of 928 patients in this study. There were no differences in the patient characteristics of smoking status, nonsteroidal use, or history of irritable bowel syndrome across the 4 study groups. Patients with surgically treated diverticulitis had significantly more episodes of diverticulitis (2.8 ± 1.9) than the medically treated group (1.4 ± 0.8) (p0.0001). The rate of appendectomy was 8.2% for the diverticulosis control group, 13.5% in the cancer group, 23.5% in the medically treated diverticulitis group, and 24.5% in the surgically treated diverticulitis group (p0.0001). After adjusting for demographics and other clinical risk factors, patients with diverticulitis had 2.8 times higher odds of previous appendectomy (p0.001) than the control groups.The retrospective study design is associated with selection, documentation, and recall bias.Our data reveal significantly higher appendectomy rates in patients with a diagnosis of diverticulitis, medically or surgically managed, in comparison with patients with incidentally identified diverticulosis. Therefore, we propose that appendicitis and diverticulitis share similar risk factors and potentially a common pathological link.

We sought to determine the accuracy of the Model for End-Stage Liver Disease and the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator in patients with ascites who underwent colorectal surgery. The National Surgical Quality Improvement Program database was queried for patients with ascites who underwent a major colorectal operation. Predicted 90-day mortality rate based on the Model for End-Stage Liver Disease and 30-day mortality based on the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator were compared with observed 30-day mortality. The cohort contained 3137 patients with ascites who underwent a colorectal operation. The Model for End-Stage Liver Disease predicted that 252 (8 %) of patients with ascites undergoing colorectal operations would die within 90 days postoperatively, yet we observed 821 deaths (26 % mortality) within 30 days after surgery (p < 0.001). The Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator predicted that 491 (16.6 % mortality) of patients with ascites undergoing colorectal operations would die within 30 days postoperatively, yet we observed 707 (23.9 % mortality) at 30 days (p < 0.01). We concluded that the current risk prediction models significantly under predict mortality in patients with ascites who underwent colorectal surgery.

Readmissions pose a significant hardship for patients and constitute a major quality and financial concern for hospitals. We sought to define risk factors associated with hospital readmission after colorectal surgery at a tertiary care hospital. We evaluated readmission among all patients who underwent a colorectal surgical procedure between July 16, 2007 and June 30, 2011. In a cohort of 4879 operative encounters, 492 (10%) were readmitted to the hospital within 30 days of discharge. Procedures with highest readmissions included stoma creation (22%), ileoanal pouch surgery (22%), and total proctocolectomy (30%). In multivariate analysis, the following variables were associated with risk of readmission: postoperative complication, use of anxiolytics, high comorbidity score, patient setting, alcohol use, and stoma creation. Surgeon of record was not associated with readmission. In conclusion, several patient, procedural, and postoperative factors were associated with an increased risk of readmission. Considerably high rates of readmission were noted after stoma creation, ileoanal pouch procedures, and proctocolectomy. Surgeon of record was not associated with risk of read-mission, indicating little value to this metric as a physician-specific indicator of quality.

In rectal cancer surgery, low anterior resection and abdominoperineal resection have equivocal impact on overall quality of life. A rectal cancer decision aid was developed to help patients weigh features of options and share their preference.The aim of this study was to evaluate the effect of a patient decision aid for mid to low rectal cancer surgery on the patients' choice and decision-making process.A before-and-after study was conducted. Baseline data collection occurred after surgeon confirmation of eligibility at the first consultation. Patients used the patient decision aid at home (online and/or paper-based formats) and completed post questionnaires.This study was conducted at an academic hospital referral center.Adults who had rectal cancer at a maximum of 10 cm proximal to the anal verge and were amenable to surgical resection were considered. Those with preexisting stoma and those only receiving abdominoperineal resection for technical reasons were excluded from the study.Patient with rectal cancer were provided with a decision aid.The primary outcomes measured were decisional conflict, knowledge, and preference for a surgical option.Of 136 patients newly diagnosed with rectal cancer over 13 months, 44 (32.4%) were eligible, 36 (81.9%) of the eligible patients consented to participate, and 32 (88.9%) patients completed the study. The mean age of participants was 61.9 ± 9.7 years and tumor location was on average 7.3 ± 2.1 cm above the anal verge. Patients had poor baseline knowledge (52.5%), and their knowledge improved by 37.5% (p0.0001) after they used the patient decision aid. Decisional conflict was reduced by 24.2% (p = 0.0001). At baseline, no patients preferred a permanent stoma, and after decision aid exposure, 2 patients (7.1%) preferred permanent stoma. Over 96% of participants would recommend the patient decision aid to others.This study was limited by the lack of control for potential confounders and potential response bias.The patient decision aid reduced decisional conflict and improved patient knowledge. Participants would recommend it to other patients with rectal cancer.

We propose that prolonged colorectal surgery operative times are associated with increased 30-day adverse events. We identified a cohort from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 2005 through December 2012. Patients who underwent colectomy with primary anastomosis were selected using CPT codes. Operative time was categorized into short, average, and long based on mean operative times ±1 SD. NSQIP-approved multivariate models were used to identify associations between operative time and 30-day adverse events. A total of 113,615 patients underwent colorectal resection of which 46 per cent were laparoscopic and 12 per cent were identified as long operative times. Patients with long operative procedures had 34 per cent more superficial surgical site infections, 65 per cent more organ space infections, 69 per cent more abdominal dehiscences, 44 per cent more thrombotic complications, 45 per cent more urinary tract infections, 40 per cent more returns to the operating room, and 36 per cent more prolonged lengths of stay (P0.05 for all analyses). The multivariable analysis revealed an association between long operative times and increased adverse events despite adjustment for all NSQIP recommended covariates. Our results reveal increased 30-day adverse events with increased operative time. We propose that operative time may serve as a proxy for surgical complexity in colorectal surgery.

One academic medical center's efforts to move toward compliance with requirements ofRequirements ofAchieving

Competence in colon and rectal surgery requires a unique set of technical skills, in addition to sound judgment and devoted patient care. Assessment of technical competence is central to defining and maintaining standards and to providing constructive trainee feedback. This review aims to appraise the instruments that are available to assess technical competence in colon and rectal surgery and discuss how these can be best utilized in assessing technical competence.

BACKGROUND Efforts to improve the quality of surgical care and reduce morbidity and mortality have resulted in outcomes reporting at the service and institutional level. Surgeon-specific outcomes are not readily available. OBJECTIVE The aim of this study is to compare surgeon-specific outcomes from the National Surgical Quality Improvement Program and 100% capture institutional quality data. DESIGN We conducted a cohort study evaluating institutional and surgeon-specific outcomes following colorectal surgery procedures at 1 institution over 5 years. PATIENTS All patients who underwent an operation by a colorectal surgeon at Lahey Hospital & Medical Center from January 1, 2008 through December 31, 2012 were identified. MAIN OUTCOME MEASURES Thirty-day mortality, reoperation, urinary tract infection, deep vein thrombosis, pneumonia, superficial surgical site infection, and organ space infection were the primary outcomes measured. ANALYSIS We compared annual and 5-year institutional and surgeon-specific adverse event rates between the data sets. In addition, we categorized individual surgeons as low-outlier, average, or high-outlier in relation to aggregate averages and determined the concordance between the data sets in identifying outliers. Concordance was designated if the 2 databases classified outlier status similarly for the same adverse event category. RESULTS In the 100% capture institutional data, 6459 operative encounters were identified in comparison with 1786 National Surgical Quality Improvement Program encounters (28% sampled). Annual aggregate adverse event rates were similar between the institutional data and the National Surgical Quality Improvement Program. For annual surgeon-specific comparisons, concordance in identifying outliers between the 2 data sets was 51.4%, and gross discordance between outlier status was in 8.2%. Five-year surgeon-specific comparisons demonstrated 59% concordance in identifying outlier status with 8.2% gross discordance for the group. LIMITATIONS The inclusion of data from only 1 academic referral center is a limitation of this study. CONCLUSIONS Each surgeon was identified as a "high outlier" in at least 1 adverse event category. Comparisons at the annual and 5-year points demonstrated poor concordance between our 100% capture institutional data and the National Surgical Quality Improvement Program data.

The delivery of an accurate dose of a compounded sterile product (CSP) is paramount to ensuring effective treatment and preventing patient harm. Cases of patient harm due to errors in the production of CSPs have been widely documented.[1][1] An observational study at 5 U.S. hospitals that prepare

The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement.The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation.During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ0.8), a user-friendly tool was validated among a large group of blinded, trained experts.The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee.Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons.Assessment tool reliability and internal consistency were measured.From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006).The study was limited by rater bias to technique and style.The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Background: Drug manufacturers change distribution models based on patient safety and product integrity needs. These model changes can limit health-system access to medications, and the financial impact on health systems can be significant. Objective: The primary aim of this study was to determine the health-system financial impact of a manufacturer’s change from open to limited distribution for bevacizumab (Avastin), rituximab (Rituxan), and trastuzumab (Herceptin). The secondary aim was to identify opportunities to shift administration to outpatient settings to support formulary change. Methods: To assess the financial impact on the health system, the cost minus discount was applied to total drug expenditure during a 1-year period after the distribution model change. The opportunity analysis was conducted for three institutions within the health system through chart review of each inpatient administration. Opportunity cost was the sum of the inpatient administration cost and outpatient administration margin. Results: The total drug expenditure for the study period was $26 427 263. By applying the cost minus discount, the financial effect of the distribution model change was $1 393 606. A total of 387 administrations were determined to be opportunities to be shifted to the outpatient setting. During the study period, the total opportunity cost was $1 766 049. Conclusion: Drug expenditure increased for the health system due to the drug distribution model change and loss of cost minus discount. The opportunity cost of shifting inpatient administrations could offset the increase in expenditure. It is recommended to restrict bevacizumab, rituximab, and trastuzumab through Pharmacy & Therapeutics Committees to outpatient use where clinically appropriate.

Background ACS-NSQIP classifies hospitals as “high outliers” if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers. Methods Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008–2011 for 13 postoperative adverse events. Pearson correlation and R 2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate. Results Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance. Conclusions Outlier status may be less meaningful for adverse events with relatively few outlier hospitals.

Rectovaginal fistula represents a challenging and often frustrating clinical entity for patients and surgeons alike. Despite a plethora of available approaches for repair, rates of non-healing and recurrence remain high. As a result, patients often require multiple attempts at repair before a satisfactory outcome is achieved. The surgical literature is replete with observational studies consisting of single-institution case series; however, there is a lack of level 1 evidence to support definitive recommendations. In this chapter, we summarize the available literature regarding procedures used to treat recurrent rectovaginal fistulas, then, supplement this with recommendations and observations from clinical practice. Specifically, we focused on endorectal/mucosal advancement flaps, tissue transposition techniques, and biologic mesh repair.

The rate of reoperation after transabdominal as compared with transperineal repair for rectal prolapse is unknown. We evaluated all patients who underwent surgical treatment for rectal prolapse performed through transabdominal or transperineal repair from the trackable California Inpatient data files and Revisit Analyses during the time period of January 1, 2005, through December 31, 2007. We specifically evaluated rates of reoperation and stoma formation during the 36-month study period. A total of 3400 patient discharges with rectal prolapse from California during the 36-month study period was identified. Of this cohort, 1772 patients had one or more prolapse repairs. Procedures were more likely to be performed through a transabdominal (1035 [58%]) as compared with a transperineal approach (737 [42%]). There was no difference in reoperation for transabdominal (11%) as compared with transperineal procedures (11%; P = 0.9). However, a significantly larger proportion of patients underwent stoma formation after transabdominal (8%) as compared with transperineal repair (5%; P < 0.02). Time to reoperation was not significantly different for patients treated with transabdominal (295 ± 254 days) as compared with transperineal repair (271 ± 246 days; P = 0.6). In conclusion, the risk of reoperation is substantial for both transabdominal and transperineal procedures for rectal prolapse.

Validated risk adjustment programs do not use patient diagnosis as a potential covariate in the evaluation of organ space infections.We hypothesized that patient diagnosis is an important risk factor for organ space infection after colorectal resections.We conducted a retrospective cohort study abstracting data from the American College of Surgeons National Surgical Quality Improvement Program from January 2005 through December 2009.Patients who underwent 1 of 3 types of colorectal resections (ileocolostomy, partial colectomy, and coloproctostomy) were identified by the use of Current Procedural Terminology codes. We excluded patients with concomitant formation of diverting or end stoma.The primary outcome measured was organ space infection.Validated risk adjustment models were used with the addition of diagnostic codes.We identified 52,056 patients who underwent a colorectal resection of whom 1774 patients developed an organ space infection (3.4%) and 894 (50.2%) returned to the operating room for further surgery. For ileocolostomy, operations for endometriosis (OR, 7.8; 95% CI, 1.7-36.6) and intra-abdominal fistula surgery (OR, 3.0; 95% CI, 1.5-6.0) were associated with increased risk of organ space infection. For partial colectomy, operations for intra-abdominal fistula surgery (OR, 2.3; 95% CI, 1.2-4.3), IBD (OR, 2.5; 95% CI, 1.6-3.8), and bowel obstruction (OR, 1.8; 95% CI, 1.2-2.6) were associated with an increased risk of organ space infection. For coloproctostomy, operations for malignant neoplasm (OR, 2.2; 95% CI, 1.1-4.3) and diverticular bleeding (OR, 3.1; 95% CI, 1.1-9.0) were associated with an increased risk of organ space infection.This study was limited by the retrospective study design.After adjustment for National Surgical Quality Improvement Program covariates, intra-abdominal fistula, endometriosis, and diverticular bleeding were the diagnoses associated with the highest risk of organ space infection following colorectal resections.

BACKGROUND The National Comprehensive Cancer Network recommends routine reevaluation of all stage II colon cancer specimens with fewer than 12 lymph nodes. However, there are few data demonstrating the effect of reevaluation on stage. OBJECTIVE The aim of this study was to demonstrate the effect of pathologic reevaluation for colorectal cancers with fewer than 12 lymph nodes on stage. DESIGN This study entailed a retrospective review of pathology reports. SETTINGS This study was conducted at 2 large multispecialty referral centers. INTERVENTIONS Pathologic reevaluation was performed to look for additional lymph nodes. PATIENTS All patients with stage I through III colorectal cancers with inadequate lymph node yields who underwent reevaluation from January 1, 2007 through March 31, 2011 were identified. MAIN OUTCOME MEASURES We recorded initial pathologic stage and new stage following reevaluation. The following variables before and after reevaluation were also recorded: 1) total lymph node count, 2) metastatic node count, 3) negative node count, and 4) lymph node ratio. RESULTS Eighty-three patients underwent pathologic reevaluation from a total of 1682 cancer specimens. Mean nodal yields were 7.2 ± 2.6 on the first pathologic review. On reevaluation, 80% of patients had one or more newly identified nodes. On average, 6.9 ± 9.6 more lymph nodes were identified with a metastatic node detected in 4 of 83 patients (4.8%). After pathologic reevaluation, 1 patient (1.2%) had a change in TNM stage from N1 to N2 disease. The lymph node ratio changed in 13 of 15 patients (87% of stage III cancers). Only 4 of these had a change in lymph node quartile. LIMITATIONS The study was limited by its retrospective nature and small sample size. CONCLUSION Few patients have a newly discovered metastatic node or stage change following pathologic reevaluation. The effect of pathologic reevaluation on treatment and outcome should be further investigated.

In this study we sought to identify changes in the etiology and surgical treatment of acute gastrointestinal perforations in the United States over the past 20 years. We performed a retrospective review of the Nationwide Inpatient Sample from January 1, 1988, through December 31, 2007. We first identified all patients with gastrointestinal perforations, the perforated organ, and treatment rendered. During the study period, 550,132 patients experienced a gastrointestinal perforation for a mean rate of 3.9 cases per 1,000 discharges. Total number of perforations rose significantly over the study period, yet surgical procedures were performed in less than half of the patients (47.6%). The most common surgical procedures for gastrointestinal perforation were colorectal in origin (38.3%), upper gastrointestinal tract (30.0%), small intestine (29.2%), esophagus (3.0%), and anus (0.1%). At study end, colorectal procedures for perforation were the most commonly performed (40.4%), whereas upper gastrointestinal procedures experienced the greatest decline. In conclusion, our data demonstrate a decline in procedures for upper gastrointestinal perforation and an increase in colorectal procedures during the two-decade study period. These data should be used to assist in the training of acute care surgeons.

To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS).It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards.A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice."The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent.The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

There has been increased attention focused on reducing postoperative length of stay and mortality following colorectal surgery. We sought to identify adverse events associated with prolonged length of stay and mortality. We evaluated postoperative “adverse events,” prolonged length of stay, and mortality within 30 days of colorectal surgery in the National Surgical Quality Improvement Program (NSQIP) hospitals from January 2005 through December 2008. We then used multivariate models to establish the associations between adverse events and prolonged length of stay and mortality. A total of 54,237 patients underwent colorectal surgery: 39,980 (74 %) experienced no postoperative adverse events, while 14,257 (26 %) experienced one or more adverse events. Length of stay was prolonged (longer than 10 days) in 38 % of patients who experienced a postoperative adverse event and in 15 % of patients without events. Mortality increased with the number of postoperative adverse events. In multivariate models including preoperative comorbidity, patient risk factors, and adverse events, patients who experienced a cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure were at highest odds of dying within 30 days of surgery. Patients with cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure are at highest risk of mortality following colorectal surgery.