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Objective: Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients., Background: In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients., Methods: Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. χ and logistic regression analysis were used to assess the effect of AL on mortality., Results: We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744-5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177-3.507), and open approach (OR 2.124; 95% CI, 1.194-3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328-0.969)., Conclusions: AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.

Objective: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy., Background: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature., Study Design: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy., Settings: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012., Patients: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study., Outcome Measures: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures., Results: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery., Limitations: The limitations of this study include its retrospective nature and that it was performed at a single institution., Conclusions: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Background: Often, minor complications are not reported in morbidity and mortality (M&M) conference because they are considered insignificant to patient outcome. As part of an effort to improve the quality of the M&M conference, we sought to integrate a specific, focused intervention to improve the reporting of minor complications and to evaluate the perception of its educational value., Materials and Methods: To provide evidence-based training in recognizing, treating, and preventing minor complications, a presentation strategy was created. Surgical faculty identified 20 complications as minor complications. Each month, a junior resident was assigned to give a 10-minute presentation, assessing 1 of the 20 minor complications in depth during the M&M conference. To assess the impact of the intervention, we surveyed residents and faculty about the educational value of M&M conferences before and after implementation., Results: Before introducing minor complication presentations into the M&M conference, only 58% of respondents indicated that minor complications should be reported at the conference. After the changes were implemented in minor complication reporting, 95% of respondents said that minor complications should be reported (p < 0.01). Eighty-nine percent of respondents found the minor complication presentations to be educationally beneficial. In addition, postsurvey respondents were also more likely than presurvey respondents to identify that a purpose of an M&M conference was to improve patient care (29% vs 71%, p < 0.05)., Conclusions: A formal, evidence-based presentation of minor complications can increase both the faculty and residents' perception of the importance of reporting minor complications at an M&M conference. Focused minor complication reporting should be incorporated into M&M curriculum., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We have undertaken the current study to evaluate factors that correlate with postoperative complications in older patients undergoing surgery for colon cancer., Patients and Methods: The database of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from years 2005 to 2008 was accessed. Patients age 65 and older were included according to Current Procedural Terminology and International Classification of Disease-9 codes. Preoperative and operative variables were examined and postoperative complications assessed using a combination of univariate and multivariate statistical models. Propensity score matching was used to control for nonrandomization of the database., Results: We found that patients undergoing laparoscopic (n = 2113) and open (n = 3801) surgery for the diagnosis of colon cancer were similar in age and gender. However, patients undergoing laparoscopic surgery were generally at lower risk for developing postoperative complications (16.1% vs. 25.4%, P < 0.005). Statistical models controlling for preoperative and operative variables demonstrated patients with elevated body mass index (odds ratio [OR] = 1.26), a history of chronic obstructive pulmonary disease (OR = 1.63), over age 85 (OR = 1.35), a surgery lasting longer than 4 hours (OR = 1.48), or having undergone an open operation (OR = 1.53) to have increased risk for developing postoperative complications. Propensity score match analysis confirmed these results., Conclusions: Identification of preoperative factors that predispose patients to postoperative complications could allow for the institution of protocols that may decrease these events. Furthermore, expanding the role of laparoscopy in the treatment of older patients with colon cancer may decrease rates of postoperative complications.

Objective: Compare outcomes of non-emergent laparoscopic to open colon surgery., Background: Laparoscopy has revolutionized much of gastrointestinal surgery. Colon and rectal surgery has seen drastic changes with many of the abdominal operations being performed laparoscopically. However, data comparing recovery and complications in patients undergoing laparoscopic and open colon surgery has shown only slight benefits for laparoscopy. Given the large benefits of laparoscopy in most gastrointestinal surgical procedures, this outcome is surprising. We, therefore, have set out to test the hypothesis that laparoscopic approaches decreases postoperative complications., Methods: We have undertaken a review of the database maintained by the American College of Surgeon's National Surgical Quality Improvement Program. We have identified 8660 patients who met inclusion criteria for this study. Postoperative complication data were collected for patients undergoing laparoscopic or open colon surgery. Using a combination of univariate and multivariate analyses we evaluated for statistical significance., Results: We found that laparoscopy decreased overall complications as well as individual complications. We found a decreased length of stay as well as a decreased risk for postoperative complications in the elderly. We found that laparoscopy decreased complication rate independent of the probability of morbidity statistic., Conclusions: When controlled for probability of morbidity, laparoscopy decreases the rate of postoperative complications. Given the equivalent outcomes of laparoscopic approaches, we conclude that laparoscopy should be offered to all patients who lack an absolute contraindication for laparoscopic surgery.

Purpose: Anastomotic disruption is an uncommon but morbid complication of colon and rectal surgery. This study was designed to evaluate the use of proximal diversion and surgical drainage as an alternative to anastomotic resection in the operative management of patients with anastomotic complications., Methods: A retrospective chart review was undertaken of all patients on the colon and rectal surgery service at an academic medical center requiring operative intervention for an anastomotic complication between 1998 and 2005. Demographic data, operative management, morbidity, and mortality were collected and analyzed for each patient., Results: Twenty-seven patients with anastomotic leaks were included in the study. Nineteen patients were managed with proximal diversion and surgical drainage, six patients had resection of their anastomosis and creation of an end colostomy, and two patients were treated by primary reanastomosis. There was 0 percent mortality. Sixty-three percent of the patients treated with proximal diversion had restoration of intestinal continuity vs. 33 percent of the patients who had the anastomosis resected. Of the 13 patients treated with proximal diversion who underwent fluoroscopic evaluation, 92 percent were normal without evidence of persistent leak or stricture., Conclusions: Based on this retrospective study, proximal diversion without resection of the anastomosis seems to be a safe and effective alternative for the treatment of anastomotic complications. Sepsis is well controlled with limited mortality and there is a high rate of anastomotic salvage. Prospective studies are needed to further delineate the optimal management for this complicated patient population.