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Importance: The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice., Objective: To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings., Design, Setting, and Participants: This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019., Exposures: Receipt of robotic colectomy., Main Outcomes and Measures: Incidence of postoperative medical and surgical complications and length of stay., Results: A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients])., Conclusions and Relevance: While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Background: Although most surgical outcomes research focuses on clinical end points and complications, older adult patients may value functional outcomes more. However, little is known about the risk of long-term functional disability after colorectal procedures., Objective: The purpose of this research was to understand the incidence and likelihood of functional decline after high-risk (ie, ≥1% inpatient mortality) colorectal operations both without and with complications., Design: This was a retrospective matched cohort study., Settings: The Health and Retirement Study, a nationally representative, longitudinal survey of adults >50 years of age, collects data on functional status, cognition, and demographics, among other topics. The survey was linked with Medicare claims and National Death Index data from 1992 to 2012., Patients: Patients ≥65 years of age who underwent elective high-risk colorectal surgery with functional status measured before and after surgery were included. These patients were matched 1:3 to survey respondents who did not undergo major surgery, based on propensity scores., Main Outcome Measures: Functional decline, the primary outcome, was defined as an increase in the number of activities of daily living and instrumental activities of daily living requiring assistance before and after surgery. Using logistic regression, we examined whether surgery without or with complications was associated with functional decline., Results: We identified 289 patients who underwent high-risk colorectal surgery and 867 matched control subjects. Of the surgery patients, 90 (31%) experienced a complication. Compared with the control subjects, surgery patients experienced greater likelihood of functional decline (without complications: OR = 1.82 (95% CI, 1.22-2.71), and with complications: OR = 2.96 (95% CI, 1.70-5.14)). Increasing age also predicted greater odds of functional decline (OR = 2.09, per decade (95% CI, 1.57-2.80))., Limitations: The functional measures were self-reported by survey participants., Conclusions: High-risk colorectal surgery, without or with complications, is associated with increased likelihood of functional decline in older adults. Patient-centered decision-making should include discussion of expected functional outcomes and long-term disability. See Video Abstract at http://links.lww.com/DCR/B78. PÉRDIDA DE LA FUNCIONALIDAD A LARGO PLAZO LUEGO DE CIRUGÍA ELECTIVA COLORRECTAL DE ALTO RIESGO EN EL PACIENTE AÑOSO: Aunque en la mayoría de las investigaciones los resultados quirúrgicos se centran en los puntos finales clínicos y las complicaciones, actualmente se pueden valorar los resultados funcionales en el paciente añoso. Sin embargo, se sabe poco sobre el riesgo de la discapacidad funcional a largo plazo después de un procedimiento colorrectal.Comprender la incidencia y la probabilidad del deterioro funcional después de operaciones colorrectales de alto riesgo (es decir, ≥1% de mortalidad hospitalaria) con y sin complicaciones.Estudio de cohorte emparejado retrospectivo.El seguimiento longitudinal representativo a nivel nacional en adultos de >50 años y que recopila datos sobre su estado funcional, su estado cognitivo y su demografía, entre otros temas es el llamado "Estudio de Salud en jubilados." La encuesta se vinculó con los reclamos de Medicare y los datos del Índice Nacional de Defunciones entre 1992 y 2012.Aquellos de ≥65 años que se sometieron a cirugía colorrectal electiva de alto riesgo con un estado funcional medido antes y después de la cirugía. Estos pacientes se compararon 1: 3 con los encuestados que no se sometieron a cirugía mayor, según puntajes de propensión.La disminución functional como resultado primario, se definió como un aumento en el número de actividades de la vida diaria y actividades instrumentales de la vida diaria que requieren asistencia antes y después de la cirugía. Mediante la regresión logística, evaluamos si la cirugía sin complicaciones y/o con complicaciones se asoció con un deterioro funcional.Identificamos 289 pacientes que se sometieron a cirugía colorrectal de alto riesgo y 867 controles pareados. De los pacientes de cirugía, 90 (31%) experimentaron algun tipo de complicación. En comparación con los controles, los pacientes de cirugía experimentaron una mayor probabilidad de deterioro funcional (sin complicaciones: OR 1.82, IC 95% 1.22-2.71, y con complicaciones: OR 2.96, IC 95% 1.70-5.14). El aumento de la edad también predijo mayores probabilidades en el deterioro funcional (OR 2.09, por década, IC 95% 1.57-2.80).Las medidas funcionales fueron autoinformadas por los participantes de la encuesta.La cirugía colorrectal de alto riesgo, con o sin complicaciones, se asocia con una mayor probabilidad de deterioro funcional en adultos mayores. La toma de decisiones centradas en el paciente deben incluir la discusión de los resultados funcionales esperados y la discapacidad a largo plazo. Vea el resumen del video en http://links.lww.com/DCR/B78.

Background: There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes., Objective: This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes., Design: This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome., Setting: January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative., Patients: A total of 2947 patients undergoing elective colectomy were selected., Main Outcome Measures: The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments., Results: The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04)., Limitations: This study focused on outcomes and did not consider processes of care as drivers of value., Conclusions: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMÍA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atención quirúrgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprensión de las interacciones entre el rendimiento clínico, utilización eficiente de los servicios y costos de los episodios quirúrgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomía sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago múltiple y resultados clínicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuación de valor (proporción de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el análisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clínico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 días, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomía electiva.Pagos por episodio de 30 días, ajustados al riesgo y estandarizados por precio.La tasa media de complicación ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pagó $3807 (17%) más que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) más altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centró en los resultados y no se consideraron a los procesos de atención, como impulsores de valor.En la colectomía electiva, los hospitales de alto valor logran pagos de episodios más bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, más allá que la reducción de complicaciones. Objetivos valiosos para optimizar el valor de la colectomía electiva, pueden incluir mejoras en los protocolos de recuperación, así como otras intervenciones que aumenten la eficiencia en todas las fases de la atención. Vea el resumen del video en http://links.lww.com/DCR/B56.

Importance: Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons., Objective: To assess rates of complications for MIC compared with OC among surgeons., Design, Setting, and Participants: We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches., Main Outcomes and Measures: Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC., Results: Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC., Conclusions and Relevance: Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Importance: As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions., Objective: To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions., Design, Setting, and Participants: This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period., Exposure: Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers., Main Outcomes and Measures: Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care., Results: A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period., Conclusions and Relevance: Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

This article discusses the commonly encountered operative procedures of the colon and urinary diversions and provides a comprehensive review of indications, contraindications, surgical techniques with emphasis on normal and abnormal multimodality imaging findings.

Background: Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness., Methods: This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality., Results: A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups., Conclusions: When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Background: Patients with colorectal cancer (CRC) may suffer significant economic hardship during treatment. Complications are common after surgery for CRC and may exacerbate the financial burden of CRC even further., Methods: Within a population-based survey of patients with stage III CRC, the authors investigated the effects of disease and treatment on personal finances and computed a composite measure of financial burden. Correlations were examined between components of financial burden and patient-reported postoperative complications using chi-square analyses, and Mantel-Haenszel chi-square tend tests were used to evaluate correlations between composite financial burden scores and surgical complications, controlling for patient characteristics and other factors by using multivariable Poisson regression., Results: Among 937 respondents, 224 (24%) reported complications after surgery. Those with complications had significantly higher composite financial burden (P < .001 for trend): they were more likely to spend savings (40% vs 31%; P  = .01), borrow or take loans (18% vs 11%; P = .007), fail to make credit card payments (18% vs 11%; P = .005), reduce spending for food or clothes (38% vs 27%; P = .001), and decrease recreational activities (41% vs 33%; P = .03). They took significantly longer to return to work (P  = .009) and were more likely to experience significant worry about finances (61% vs 52%; P = .01)., Conclusions: Complications after surgery for CRC result in significant personal financial consequences as well as morbidity. Financial stress impairs quality of life and may prevent adherence to recommended treatments. Therefore, patients who suffer complications may require not just additional clinical care but also economic support and services., (© 2014 American Cancer Society.)

Background: Trust in physicians is an essential part of therapeutic relationships. Complications are common after colorectal cancer procedures, but little is known of their effect on patient-surgeon relationships. We hypothesized that unexpected complications impair trust and communication between patients and surgeons., Methods: We performed a population-based survey of surgically diagnosed stage III colorectal cancer patients in the Surveillance Epidemiology and End Results registries for Georgia and Metropolitan Detroit between August 2011 and October 2012. Using published survey instruments, we queried subjects about trust in and communication with their surgeon. The primary predictor was the occurrence of an operative complication. We examined patient factors associated with trust and communication then compared the relationship between operative complications and patient-reported trust and communication with their surgeons., Results: Among 622 preliminary respondents (54% response rate), 25% experienced postoperative complications. Those with complications were less likely to report high trust (73% vs 81%, P = .04) and high-quality communication (80% vs 95%, P < .001). Complications reduced trust among only 4% of patient-surgeon dyads with high-quality communication, whereas complications diminished patients' trust in 50% with poorer communication (P < .001). After controlling for communication ratings, we found there was no residual effect of complications on trust (P = .96)., Conclusion: Most respondents described trust in and communication with their surgeons as high. Complications were common and were associated with lower trust and poorer communication. However, the relationship between complications and trust was modified by communication. Trust remained high, even in the presence of complications, among respondents who reported high levels of patient-centered communication with their surgeons., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Object: The surgical Apgar score (SAS) reliably predicts postoperative death and complications and has been validated in a large cohort of general and vascular surgery patients. However, there has been limited study of the utility of the score in the neurosurgical population. The authors tested the hypothesis that the SAS would predict postoperative complications and length of stay after neurosurgical procedures., Methods: A cohort of 918 intracranial and spine surgery patients treated over a 3-year period were retrospectively evaluated. The 10-point SAS was calculated and postoperative 30-day mortality and complications rates, intensive care unit (ICU) stay, and hospital stay were assessed by 2 independent raters. Univariate analysis and multivariate logistic regression were performed., Results: There were 145 patients (15.8%) with at least 1 complication and 24 patients (2.6%) who died within 30 days of surgery. Surgical Apgar scores were significantly associated with the likelihood of postoperative complications (p < 0.001) and death (p = 0.002); scores varied inversely with postoperative complication and mortality risk in a multivariate analysis. Low SASs also predicted prolonged ICU and hospital stay. Patients with scores of 0-2 stayed a mean of 18.9 days (p < 0.001) and patients with scores of 3-4 stayed an average of 14.3 days (p < 0.001) compared with 4.1 days in patients with scores of 9-10., Conclusions: The application of the surgical Apgar score to a neurosurgical cohort predicted 30-day postoperative mortality and complication rates as well as extended ICU and hospital stay. This readily calculated score may help neurosurgical teams efficiently direct postoperative care to those at highest risk of death and complications.

Background: Surgical care is a vital component of health care worldwide, yet there is no clinically meaningful measure of operative outcomes that could be applied globally. The Surgical Apgar Score, a simple metric derived from 3 intraoperative parameters, has been shown in U.S. academic medical centers to predict 30-day patient outcomes after operation, but has not been validated more broadly., Methods: We collected the components of the Surgical Apgar Score at the time of operation for 5,909 adult patients undergoing noncardiac operative procedures under general anesthesia at 8 hospitals in diverse international settings and evaluated the relationship between patients' scores and the incidence of inpatient postoperative morbidity and mortality, using generalized estimating equations to adjust for clustering within sites., Results: During the first 30 days of postoperative hospitalization, 544 patients (9.2%) experienced ≥ 1 complications. Compared with patients with the median score of 7--whose complication rate was 9.1%-those with a Surgical Apgar Score <5 (n = 302) had an adjusted complication rate of 32.9% (relative risk [RR],3.6; 95% CI, 2.9-4.5), whereas those with a score of 10 (n = 238) had a 3.0% adjusted complication rate (RR, 0.3; 95% CI, 0.1-1.1). The score's c-statistic for prediction of any complication is 0.70; for death it is 0.77., Conclusion: The Surgical Apgar Score is easily calculated, predictive, and moderately discriminative for major complications among adults undergoing inpatient noncardiac operative procedures. Such a score could provide objective indication of relative postoperative risk for inpatients and provide a potential target for quality improvement efforts, particularly in resource-limited settings., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: A 10-point Surgical Apgar Score, based on patients' estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery, was developed to rate patients' outcomes in general and vascular surgery but has not been tested for patients having orthopaedic surgery., Questions/purposes: For patients undergoing hip and knee arthroplasties, we asked (1) whether the score provides accurate risk stratification for major postoperative complications, and (2) whether it captures intraoperative variables contributing to postoperative risk based on the three parameters independent of preoperative risk., Patients and Methods: We retrospectively reviewed the electronic records for all 3511 patients who underwent a hip or knee arthroplasty from March 2003 to August 2006 and extracted data to calculate a Surgical Apgar Score. We evaluated the relationship between scores and likelihood of major postoperative in-hospital complications and assessed its discrimination and calibration., Results: Complication rates increased monotonically as the score decreased. Even after controlling for preoperative risk, each 1-point decrease in the score was associated with a 34.0% increase (95% confidence interval, 0.66-0.84) in the odds of a complication. The overall discriminatory performance of the score was a c-statistic of 0.61. Seventy-six percent of all major complications occurred in patients classified as low risk with scores of 7 or greater., Conclusions: For patients undergoing hip and knee arthroplasties, the score captures important intraoperative information regarding risk of complications and contributes additional information to preoperative risk, but on its own is insufficient to provide comprehensive postoperative risk stratification for arthroplasties., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: We previously developed an intraoperative 10-point Surgical Apgar Score-based on blood loss, lowest heart rate, and lowest mean arterial pressure-to predict major complications after colorectal resection. However, because complications often arise after uncomplicated hospitalizations, we sought to evaluate whether this intraoperative metric would predict postdischarge complications after colectomy., Methods: We linked our institution's National Surgical Quality Improvement Program database with an Anesthesia Intraoperative Management System for all colorectal resections over 4 years. Using Chi-square trend tests and logistic regression, we evaluated the Surgical Apgar Score's prediction for major postoperative complications before and after discharge., Results: Among 795 colectomies, there were 230 (29%) major complications within 30 days; 45 (20%) after uncomplicated discharges. Surgical Apgar Scores predicted both inpatient complications and late postdischarge complications (both P < .0001). Late complications occurred from 0 to 27 (median, 11) days after discharge; the most common were surgical site infections (42%), sepsis (24%), and venous thromboembolism (16%). In pairwise comparisons against average-scoring patients (Surgical Apgar Scores, 7-8), the relative risk of postdischarge complications trended lower, to 0.6 (95% confidence interval [CI], 0.2-1.7) for those with the best scores (9-10); and were significantly higher, at 2.6 (95% CI, 1.4-4.9) for scores 5-6, and 4.5 (95% CI, 1.8-11.0) for scores 0-4., Conclusion: The intraoperative Surgical Apgar Score remained a useful metric for predicting postcolectomy complications arising after uncomplicated discharges. Even late complications may thus be related to intraoperative condition and events. Surgeons could use this intraoperative metric to target low-scoring patients for intensive postdischarge surveillance and mitigation of postdischarge complications after colectomy., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objective: To evaluate whether adherence to evidence-based best practices in colorectal surgery predicts improved postoperative outcomes., Summary and Background Data: Over a quarter of a million colon and rectal resections are performed annually in the United States. The average postoperative complication rate for these procedures approaches 30%., Methods: A panel of colorectal and general surgeons from 3 hospitals (1 academic medical center and 2 community hospitals) was assembled to ascertain a set of 37 evidence-based practices that they felt were the most pertinent to the evaluation and management of a patient undergoing a colorectal resection. Fifteen of these practices were classified as “key processes” for the prevention of complications. We then retrospectively reviewed medical records for 370 consecutive patients undergoing colorectal resection at these institutions. We evaluated the association of best-practice adherence to complications in the subset of patients with outcome data available through the American College of Surgeons National Surgical Quality Improvement Program., Results: Nonadherence rates exceeded 40% for 11 practices (including 2 key processes: avoidance of unnecessary blood transfusions and timely removal of central venous catheters). Among 198 patients with American College of Surgeons National Surgical Quality Improvement Program outcomes data, 38 (19%) experienced complications, of which 31 (82%) involved postoperative infection. Nonadherence to key-processes significantly predicted the occurrence of a complication (P = 0.002). Each additional process missed increased the odds of a postoperative complication by 60% (odds ratio: 1.6; 95% confidence interval: 1.2–2.2)., Conclusions: Failures of adherence with best practices in colorectal surgery is associated with an increased occurrence of complications. This study merits further research to confirm that improvement in compliance with perioperative best practices will reduce complication rates significantly.