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Background: Collaborative quality improvement is an established method to conduct quality improvement in surgical care. Despite the success of this method, little is known about the experiences, perceptions, and attitudes of those who participate in collaborative quality improvement. The following study elicited common themes associated with the experiences and perceptions of surgeons participating in collaborative quality improvement., Methods: We conducted an interpretive description qualitative study of surgeons participating in the Michigan Surgical Quality Collaborative, which is a statewide collaborative quality improvement consortium in Michigan. Semi-structured interviews were conducted using an interview guide., Results: A sample of 24 participants completed interviews with a mean (SD) age of 48.7 (11.5) years and 16 (80%) male participants. Two major themes were identified. First, the contextualization of individual performance was seen as key to identifying opportunities for improvement and creating motivation to improve. Contextualization of individual performance relative to peer performance was collaborative rather than punitive. Second, peer learning emerged as the primary way to inform practice change and overcome hesitancy to change. Rather than draw upon external evidence, practice change within the collaborative was informed by the practices of peer institutions. Both themes were strongly exemplified in one of the Michigan Surgical Quality Collaborative's largest initiatives-reducing excessive postoperative opioid prescribing., Conclusion: In this qualitative study of surgeons participating in statewide collaborative quality improvement, contextualization of individual outcomes and peer learning were the most salient themes. Collaborative quality improvement relied upon comparing one's own performance to peer performance, motivating improvement using this comparison, deriving evidence from peers to inform improvement initiatives, and overcoming hesitancy to change by highlighting peer success., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Surgical coaching interventions have been recommended as a method of technological skills improvement for individual surgeons and lifelong occupational learning. Patient outcomes for laparoscopic colectomy vary significantly based on surgeon experience and case volume. As surgical coaching is an emerging area, little is known about how surgeons view coaching interventions., Methods: Semistructured interviews with 68 colorectal surgeons from across the country who were e-mail recruited from the American Society of Colon and Rectal Surgeons focused on exploring the attitudes surrounding surgical coaching programs among colorectal surgeons. Interviews were performed via telephone, audio-recorded, and transcribed verbatim with redaction of identifying information. Interviews were analyzed by iterative steps informed by thematic analysis., Results: Surgeons reported the desire to participate in coaching programs to improve patient outcomes through technical skill advancement, to keep pace with surgical innovation, and to fulfill a desire for lifelong learning. However, surgeons varied in their beliefs over who should be coached, who should coach, the format of coaching, and the topics addressed in coaching. Obstacles identified included time, financial and medicolegal concerns, balance with resident education, and vulnerability., Conclusion: Widespread enthusiasm for surgical coaching programs exists among colorectal surgeons. However, there is variability in what surgeons believe an ideal surgical coaching program would look like. Therefore, in alignment with adult learning theory, we recommend the creation of several different models of surgical coaching to allow each surgeon to benefit from this advancement in continuous professional development., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement., Objective: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons., Design: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates., Settings: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals., Patients: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons., Main Outcome Measures: Main outcome measures included 30-day risk-adjusted postoperative complications., Results: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41)., Limitations: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms., Conclusions: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo)., (Copyright © The ASCRS 2021.)

Background: Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established., Objective: This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing., Design: This study is a retrospective chart review., Settings: Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes., Patients: Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction., Interventions: Immediate autologous flap reconstruction was performed after abdominoperineal resection., Main Outcome Measures: The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden., Results: Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group., Limitations: This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study., Conclusions: In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416., El Rol De La Reconstruccin Con Colgajo Autlogo En Pacientes Con Enfermedad De Crohn Sometidos a Reseccin Abdominoperineal: ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416., (Copyright © The ASCRS 2020.)

Background: The Iowa Rectal Surgery Risk Calculator estimates risk for proctectomy procedures. The Iowa Calculator performed well on NSQIP 2010-2011 training and 2005-2009 validation datasets, but was not prospectively validated and did not include low anterior resections. This study sought to demonstrate validity on new independent data, to update the calculator to include low anterior resection, and to compare performance to other risk assessment tools., Methods: Non-emergent ACS-NSQIP proctectomy and low anterior resection data from 2010 to 2015 (n = 65,683) were included. The Iowa Calculator generated risk estimates for 30-day morbidity using 2012-2015 data. An Updated Calculator used 2010-2011 training data to include low anterior resection, with validation on 2012-2015 data. NSQIP data provided NSQIP Morbidity Model predictions and a custom web-script collected ACS-NSQIP Online Surgical Risk Calculator predictions for all patients., Results: Proctectomy morbidity (not including low anterior resection) decreased from 40.4% in 2010-2011 to 37.0% in 2012-2015. Low anterior resection had lower morbidity (22.4% in 2012-15). The Iowa Calculator demonstrated good discrimination and calibration using 2012-2015 data (C-statistic 0.676, deviance + 9.2%). After including low anterior resection, the Updated Iowa Calculator performed well during training (c-statistic 0.696, deviance 0%) and validation (C-statistic 0.706, deviance + 7.9%). The Updated Iowa Calculator had significantly better discrimination and calibration than morbidity predictions from the ACS Online Calculator (C-statistic 0.693, P < 0.001, deviance - 28.1%) and NSQIP General/Vascular Surgery Model (C-statistic 0.703, P < 0.05, deviance - 40.8%)., Conclusion: When applied to new independent data, the Iowa Calculator supplies accurate risk estimates. The Updated Iowa Calculator includes low anterior resection, and both are prospectively validated. Risk estimation by the Iowa Calculators was superior to ACS-provided risk tools.

Background: Despite increasing use of robotic surgery for rectal cancer, few series have been published from the practice of generalizable US surgeons., Methods: A retrospective chart review was performed for 71 consecutive patients who underwent robotic low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010 and 2014., Results: 46 LARs (65%) and 25 APRs (35%) were identified. Median procedure time was 219 minutes (IQR 184-275) and mean blood loss 164.9 cc (SD 155.9 cc). Radial margin was negative in 70/71 (99%) patients. Total mesorectal excision integrity was complete/near complete in 38/39 (97%) of graded specimens. A mean of 16.8 (SD+/- 8.9) lymph nodes were retrieved. At median follow-up of 21.9 months, there were no local recurrences., Conclusions: Robotic proctectomy for rectal cancer was introduced into typical colorectal surgery practice by a single surgeon, with a low conversion rate, low complication rate, and satisfactory oncologic outcomes., (Copyright © 2017 John Wiley & Sons, Ltd.)

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.

Background: We aim to assess the patient factors and concomitant infectious outcomes associated with urinary tract infection (UTI) occurrence and the impact of UTI on length of stay (LOS), re-admission, and death in a colorectal surgical population., Patients and Methods: National Surgical Quality Improvement Program User Data for right colectomy and abdominal perineal resection (APR) procedures for cancer between 2006 and 2012 were analyzed. Concomitant infectious complications and timing of UTI diagnosis, inpatient versus outpatient, were considered., Results: We identified 7,615 right colectomies with 107 (1.4%) UTIs and 2,493 APRs with 88 (3.5%) UTIs (p < 0.001). On multivariable analysis and correction for other post-operative complications, UTI remained statistically correlated with prolonged LOS for right colectomy and APR (LOS increases of 59.0% and 37.4%, respectively, p < 0.001) but not death. Patients with a diagnosis of UTI after discharge showed significantly increased re-admission rates compared with UTI diagnosis before discharge (37.7% vs. 9.7%, p < 0.001)., Conclusions: After excluding deaths, outpatient UTI occurrences, and correcting for other infectious complications, UTI is associated with increased LOS but is not correlated with re-admission or death. Outpatient occurrence of UTI after hospital discharge is associated with a dramatic re-admission rate of 37.7%.

Background: Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors., Methods: We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak., Results: Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m 2 , tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 10 9 /L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak., Conclusion: This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery. Risk factors associated with conversion from robotic to open colectomy and comparisons of the risk factors between robotic and laparoscopic approaches have not been previously reported. Patients who underwent elective laparoscopic and robotic colorectal surgeries between July 1, 2012 and April 28, 2015, were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified, and hierarchical logistic regression models were used to identify risk factors for conversion. There were 4796 cases that met study inclusion criteria. Conversion was required in 18.2 % of laparoscopic and 7.7 % of robotic cases (p < 0.0001). Risk factors for conversion in the laparoscopic group included the following: moderate/severe adhesions, obesity, colorectal cancer, hypertension, rectal operations, urgent priority, and tobacco use. Risk factors for conversion in the robotic group included the following: severe adhesions, bleeding disorder, presence of cancer, cirrhosis, and use of statins. Higher surgeon volume was protective in both groups. Conversion rates are lower for robotic than for laparoscopic colorectal surgery with fewer predictors of conversion. Recognition of factors predicting conversion may allow surgeons to choose an operative approach that optimizes the benefits of the available technologies.

Background: The feasibility, safety, and costs of single-incision robotic colectomy (SIRC) are not known., Methods: A retrospective review was conducted, comparing the initial 29 consecutive SIRC procedures performed to 36 multiport laparoscopic colectomies (MLC)., Results: The groups did not differ significantly on age, body mass index, gender, ASA classification, smoking status, steroid usage or rate of diabetes. Procedure time, conversion rate, infectious complications and length of stay did not differ significantly. The ratio of observed:expected direct hospital costs statistically favoured MLC, although there was no statistical difference between groups for contribution margin, or for observed and expected direct hospital costs., Conclusions: These results demonstrate safety and technical feasibility for SIRC in selected patients with short-term outcomes and hospital costs comparable to MLC. Contribution margin remained positive and expected costs exceeded observed for SIRC. Increased costs for SIRC are a concern. The comparable but relatively high mortality in both groups may represent an institutional approach to colectomy where significant comorbidity is not a contraindication to minimally invasive surgery. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: Patient demographics and outcomes may influence patient satisfaction. We aim to investigate the relationship between postoperative complications and survey-based satisfaction in the context of payer status., Methods: Institutional data were used to identify major complication occurrence and linked to patient satisfaction surveys. The impact of complication occurrence on satisfaction was investigated and stratified by payer status., Results: In all, 1,597 encounters were identified with an 18% major complication rate. Satisfaction scores in specific domains were significantly more likely to be above the median for patients without complications (P < .01) and for payer status Medicaid/low income (P < .05). In sensitivity analyses, we found no significant interactions among payer status, complications, and satisfaction scores., Conclusions: Significant differences exist for individual satisfaction survey domains between patients with and without major postoperative complications and by payer status. Payer status was not found to have an impact on the intersection of major complications and patient satisfaction., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Hospital-acquired urinary tract infections (UTIs) significantly impact hospital outcomes. Colorectal surgery is inherently high risk for postoperative infections including UTI, and these patients may have unique outcomes as compared to other medical and surgical hospitalizations. We aim to assess the impact of the differing definitions of UTI captured by our hospital quality measures on hospital charges, length of stay (LOS), and mortality after colorectal resections at our institution., Materials and Methods: Existing hospital quality surveillance was used to retrospectively identify postcolorectal resection UTI, as defined by the National Surgical Quality Improvement Program (NSQIP), and the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN)-defined catheter-associated UTIs (CAUTI), from 2006-2012. Both groups were compared to colorectal resections performed during the same period that did not develop a UTI. Groups were compared for differences in 30-d surgical outcomes with multivariate analysis of total hospital charges and LOS., Results: During our study period, we identified 18 CAUTIs and 42 NSQIP-UTI, and 1064 other colorectal resections (UTI rate, 5.3%). Our overall mortality rate was 4.4% and was not associated with CAUTI or NSQIP-UTI on univariate analysis. CAUTI, but not NSQIP-UTI, was associated with a 73% increase in LOS and 70% increase in total hospital charges on multivariate analysis., Conclusions: By reviewing quality outcomes surveillance modalities at our hospital, we identified postcolorectal resection CAUTI, but not NSQIP-UTI, to be associated with increased total hospital charges and LOS. Neither was associated with mortality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Aim: Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States., Method: The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status., Results: Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss., Conclusion: Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)

Background: Data are limited about the robotic platform in rectal dissections, and its use may be perceived as prohibitively expensive or difficult to learn. We report our experience with the initial robotic-assisted rectal dissections performed by a single surgeon, assessing learning curve and cost., Methods: Following IRB approval, a retrospective chart review was conducted of the first 85 robotic-assisted rectal dissections performed by a single surgeon between 9/1/2010 and 12/31/2012. Patient demographic, clinicopathologic, procedure, and outcome data were gathered. Cost data were obtained from the University HealthSystem Consortium (UHC) database. The first 43 cases (Time 1) were compared to the next 42 cases (Time 2) using multivariate linear and logistic regression models., Results: Indications for surgery were cancer for 51 patients (60 %), inflammatory bowel disease for 18 (21 %), and rectal prolapse for 16 (19 %). The most common procedures were low anterior resection (n = 25, 29 %) and abdominoperineal resection (n = 21, 25 %). The patient body mass index (BMI) was statistically different between the two patient groups (Time 1, 26.1 kg/m(2) vs. Time 2, 29.4 kg/m(2), p = 0.02). Complication and conversion rates did not differ between the groups. Mean operating time was significantly shorter for Time 2 (267 min vs. 224 min, p = 0.049) and remained significant in multivariate analysis. Though not reaching statistical significance, the mean observed direct hospital cost decreased ($17,349 for Time 1 vs. $13,680 for Time 2, p = 0.2). The observed/expected cost ratio significantly decreased (1.47 for Time 1 vs. 1.05 for Time 2, p = 0.007) but did not remain statistically significant in multivariate analyses., Conclusions: Over the series, we demonstrated a significant improvement in operating times. Though not statistically significant, direct hospital costs trended down over time. Studies of larger patient groups are needed to confirm these findings and to correlate them with procedure volume to better define the learning curve process.

Background: Single-institution studies demonstrate a correlation between preoperative pelvic radiation and poor long-term pouch function after IPAA. The rarity of the radiated pelvis before these procedures limits the ability to draw conclusions on the effects of preoperative radiation on short-term outcomes, which may contribute to long-term pouch dysfunction., Objective: The purpose of this work was to better understand the impact of pelvic radiation on short-term outcomes in patients undergoing IPAA., Design: We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011)., Settings: The study was conducted at all participating NSQIP institutions., Patients: The cohort was composed of patients undergoing nonemergent IPAA procedures., Main Outcome Measures: Proportions of patients experiencing postoperative complications within 30 days were compared by Fisher exact and Wilcoxon rank-sum tests based on whether they received preoperative radiation. Multivariate logistic regression models controlled for the effects of multiple risk factors., Results: Included were 3172 patients receiving IPAA; 162 received pelvic radiation. The postoperative complication rate was not significantly different in patients receiving pelvic radiation versus not receiving pelvic radiation (p = 0.06). In a subset of patients with cancer diagnoses (n = 598), 157 received pelvic radiation; complication rates were not significantly different (p = 0.16). Patients receiving pelvic radiation had significantly lower rates of sepsis in both the overall and cancer diagnosis groups (p = 0.005 and p = 0.047), a finding which persisted after controlling for the effects of multiple risk factors (multivariate p values = 0.030 and 0.047)., Limitations: This was a retrospective database design with short-term follow-up., Conclusions: Patients who received radiation before IPAA had no difference in overall 30-day complication rates but had significantly lower rates of sepsis when compared with patients not receiving pelvic radiation. The perceived inferior long-term pouch function in patients undergoing preoperative pelvic radiation does not appear to be attributable to increases in 30-day complications.

Introduction: Surgical site infections (SSIs) after colectomy for colon cancer (CC), Crohn's disease (CD), and diverticulitis (DD) significantly impact both the immediate postoperative course and long-term disease-specific outcomes. We aim to profile the effect of diagnosis on SSI after segmental colectomy using the National Surgical Quality Improvement Program (NSQIP) data set., Method: NSQIP data from 2006 to 2011 were investigated, and segmental colectomy procedures performed for the diagnoses of Crohn's disease, DD, and colon malignancy were included. SSI complications were compared by diagnosis using univariate and multivariate analysis., Result: We included 35,557 colectomy cases in the analysis. CD had the highest rate of postoperative SSI (17 vs. 13% DD vs. 10% CC; p < 0.001). Using CC as the comparison group and controlling for multiple variables, the multivariate analysis showed that the CD group had an increased risk for acquiring at least one SSI (odds ratio (OR) = 1.38, p ≤ 0.001), deep incisional SSI (OR = 1.85, p = 0.03), and organ space SSI (OR = 1.51, p = 0.02)., Conclusion: For patients undergoing segmental colectomy in the NSQIP data set, statistically significant increases in SSI are seen in CD, but not DD, when compared to CC, thus confirming CD as an independent risk factor for SSI.

Background: Rectal surgery is associated with high complication rates, but tools to prospectively define surgical risk are lacking. Improved preoperative risk assessment could better inform patients and refine decision making by surgeons. Our objective was to develop a validated model for proctectomy risk prediction., Methods: We reviewed non-emergent ACS-NSQIP proctectomy data from 2005 to 2011 (n = 13,385). Logistic regression identified variables available prior to surgery showing independent association with 30-day morbidity in 2010-2011 (n = 5,570). The resulting risk model's discrimination and calibration were tested against the NSQIP-supplied morbidity model, and performance was validated against independent 2005-2009 data., Results: Overall morbidity for proctectomy in 2010-2011 was 40.2%; significantly higher than the 23.0 % rate predicted by the NSQIP-provided general and vascular surgery risk model. Frequent complications included bleeding (16.3%), superficial infection (9.2%), and sepsis (7.4%). Our novel model incorporating 17 preoperative variables provided better discrimination and calibration (p < 0.05) than the NSQIP model and was validated against the 2005-2009 data. A web-based calculator makes this new model available for prospective risk assessment., Conclusions: We conclude that the NSQIP-supplied risk model underestimates proctectomy morbidity and that this new, validated risk model and risk prediction tool ( http://myweb.uiowa.edu/sksherman ) may allow clinicians to counsel patients with accurate risk estimates using data available in the preoperative setting.

Background: The unique surgical challenges of proctectomy may be amplified in obese patients. We examined surgical outcomes of a large, diverse sample of obese patients undergoing proctectomy., Objective: The purpose of this work was to determine whether increased BMI is associated with increased complications in proctectomy., Design: This was a retrospective review., Settings: The study uses the American College of Surgeons National Surgical Quality Improvement Program database (2010 and 2011)., Patients: Patients included were those undergoing nonemergent proctectomy, excluding rectal prolapse cases. Patients were grouped by BMI using the World Health Organization classifications of underweight (BMI <18.5); normal (18.5-24.9); overweight (25.0-29.9); and class I (30.0-34.9), class II (35.0-39.9), and class III (≥40.0) obesity., Main Outcome Measures: We analyzed the effect of preoperative and intraoperative factors on 30-day outcomes. Continuous variables were compared with Wilcoxon rank-sum tests and proportions with the Fisher exact or χ tests. Logistic regression controlled for the effects of multiple risk factors., Results: Among 5570 patients, class I, II, and III obesity were significantly associated with higher rates of overall complications (44.0%, 50.8%, and 46.6% vs 38.1% for normal-weight patients; p < 0.05). Superficial wound infection was significantly higher in classes I, II, and III (11.6%, 17.8%, and 13.0% vs 8.0% for normal-weight patients; p < 0.05). Operative times for patients in all obesity classes were significantly longer than for normal-weight patients. On multivariate analysis, an obese BMI independently predicted complications; ORs (95% CIs) were 1.36 (1.14-1.62) for class I obesity, 1.99 (1.54-2.54) for class II, and 1.42 (1.02-1.96) for class III., Limitations: This study was a retrospective design with limited follow-up., Conclusions: Class I, II, and III obese patients were at significantly increased risk for morbidity compared with normal BMI patients. Class II obese patients had the highest rate of complications, a finding that deserves further investigation.

Background and Objectives: The effect of inflammatory bowel disease (IBD) on outcome in patients with colorectal cancer (CRC) remains unclear. Our objective is to evaluate oncologic outcomes of patients with IBD-associated CRC., Methods: We retrospectively reviewed a prospectively maintained database to identify patients with IBD-associated CRC. Clinicopathologic variables and overall survival were compared to patients with sporadic CRC using a 2:1 matched-controlled analysis., Results: Fifty-five patients with IBD and CRC were identified. On univariate analysis, CRC patients with IBD had a significantly shorter median overall survival (68.2 months vs. 204.3 months, P = 0.01) compared to patients with sporadic CRC. On multivariate analysis, after adjusting for N and M stage, IBD was associated with an increased risk of death compared to sporadic CRC (HR = 2.011, 95% CI 1.24-3.23, P = 0.004). Stage 3 CRC patients with IBD in particular showed significantly decreased survival (23.0 vs. 133.9 months, P = 0.008)., Conclusions: In this study, patients with node-positive IBD-associated CRC had a significant increased risk of death and a shorter overall survival than those with sporadic disease and may require tailored adjuvant therapy and surveillance protocols. Continued investigation to elucidate the mechanisms that contribute to these observations is justified., (© 2013 Wiley Periodicals, Inc.)

Background: The development of fulminant Clostridium difficile colitis (FCDC) requires prompt operative intervention and is associated with a high mortality rate. The aim of this study was to use a case-control design to define the clinical and laboratory parameters that predict which patients with Clostridium difficile infection are most likely to progress to FCDC., Methods: Cases from 1994 to 2006 with documented in-hospital progression of Clostridium difficile infection to FCDC were matched retrospectively at the start of medical therapy by age, sex, and intensive care unit (ICU) status to controls with Clostridium difficile infection who did not develop FCDC. Chi-Square and multivariable logistic regression were used to identify risk factors for progression to FCDC., Results: A total of 35 patients with FCDC were matched to 70 controls with Clostridium difficile infection who did not develop FCDC. The patients with FCDC underwent colectomy after an average of 4.6 days of medical therapy and had a mortality rate of 40%. On multivariate analysis, independent risk factors for the development of FCDC were a WBC > 16,000 cells/mm(3) (P < .01) at initiation of therapy, operative therapy within the last 30 days (P = .03), a history of inflammatory bowel disease (P = .04), and a history of intravenous immunoglobulin treatment (P < .01)., Conclusions: Leukocytosis, recent prior operative therapy, and a history of inflammatory bowel disease and intravenous immunoglobulin treatment were negative prognostic indicators for patients with Clostridium difficile infection. The presence of these factors merits close observation for progression to FCDC and acceleration of the planning process for operative intervention.

Objectives: To present, to our knowledge, the largest experience with colectomy for fulminant Clostridium difficile colitis and to propose factors significant in predicting mortality., Design: Retrospective medical record review., Setting: University teaching hospital., Patients: Seventy-three patients undergoing colectomy between 1994 and 2005 for C difficile-associated pseudomembranous colitis., Main Outcome Measures: Preoperative predictors of in-hospital mortality., Results: Seventy-three of 5718 cases (1.3%) of C difficile colitis required colectomy. Mean age was 68 years. In-hospital mortality was 34% (n = 25). Eighty-six percent (n = 63) of patients received a subtotal colectomy. Patients presented with diarrhea (84%; n = 61), abdominal pain (75%; n = 55), and ileus (16%; n = 12). Mean duration of symptoms was 7 days followed by 4 days of medical treatment prior to colectomy. On univariate analysis, an admitting diagnosis other than C difficile (P = .049), vasopressor requirement (P = .001), intubation (P = .001), and mental status changes (P < .001) were significant predictors of mortality. Arterial lactate level (4.9 vs 2.4 mmol/L; P = .007) was significantly higher and length of medical management (6.4 vs 3.0 days; P = .006) was significantly longer in the mortality group. Platelet counts (169 x 10(3)/microL vs 261 x 10(3)/microL [to convert to x 10(9)/L, multiply by 1]; P = .04) were significantly lower in the mortality group. On multivariate analysis, vasopressor requirement (P = .04; odds ratio, 5.0), mental status changes (P = .002; odds ratio, 12.6), and treatment length (P = .002; odds ratio, 1.4) remained significant predictors of mortality., Conclusions: Colectomy for C difficile colitis carries a substantial mortality regardless of patient age and white blood cell count. Preoperative vasopressor requirement, mental status changes, and length of medical treatment significantly predict mortality.

Purpose: The Mount Sinai Surgical Residency program uses physician assistants and nurse practitioners, jointly termed non-physician practitioners (NPPs), to adhere to the 80-hour work-week restrictions implemented by Accreditation Council of Graduate Medical Education (ACGME) resident duty hour requirements initiated in 2003. A survey was performed to determine how the integration of NPPs into the surgical subspecialty teams has affected surgical residents' perceptions of their education and overall residency experience. We review the roles of NPPs within surgical specialty teams as well as our survey findings about NPP and resident impressions about the NPP role., Methods: A survey was distributed to every surgical resident and inpatient NPP using a Likert scale for responses. The survey addressed general experiences about the NPP-resident relationship in regard to education, continuity of care, workload, communication, collaboration, role, and hierarchy. NPP responses were compared with resident responses through a Pearson chi-square test., Results: Sixty-six residents and 28 NPP responses were obtained. Overall, NPPs and residents have similar perceptions about the NPP function. Most NPPs and residents believe that having an NPP on the service decreases their workload (96.4% and 84.8%, respectively), and they believe that adequate communication and collaboration occurs between the NPPs and the residents (85.7% and 73.8% and 67.9% and 80.3%, respectively). Significantly more NPPs than residents feel that NPPs contribute to the residents' clinical education (75.0% vs 38.5%, p = 0.005) and that NPPs provide better continuity of care (96.4% vs 60.6%, p = 0.002). Although NPPs and residents believe that the NPP role is clearly defined, NPPs and residents have very different perceptions about where NPPs fall within the surgical hierarchy. Seventy-five percent of NPPs believe that they function at a senior resident level or above, whereas 90.5% of residents believe that NPPs function at the intern level or below (p < 0.001)., Conclusions: We found that at our institution, residents and NPPs agree that they work well together and that NPPs positively contribute to resident education. We recommend a service-specific orientation for the residents with each rotation to clarify NPP responsibilities and functions, thereby maximizing collaboration. With a firm understanding of the various roles of the NPPs, a cohesive, multidisciplinary group can be attained while enhancing surgical education.

We report an unusual case of necrotizing fasciitis in a 43-year-old man after elective inguinal hernia repair. The patient presented to the emergency department 9 days postoperatively with high fevers, tachycardia, and crepitus along his abdominal wall. He was treated with broad-spectrum antibiotics and underwent a diagnostic laparoscopy as well as a wide debridement of all necrotic tissue. Cultures grew out Eikenella corrodens, which, to our knowledge, has only been reported in one other case as a cause of necrotizing fasciitis. Patients can develop necrotizing fasciitis after elective, clean procedures and should be adequately resuscitated, undergo immediate surgical debridement, and receive antibiotics. Laparoscopy can be useful in determining if intraabdominal pathology is the cause of the infection and a wound vacuum-assisted device is a cost-effective way to decrease healing times.

Background: This study was designed to evaluate the impact of 3-dimensional vision on the performance of resident and experienced surgeons using the da Vinci Robot System (Intuitive Surgical, Sunnyvale, CA)., Methods: Four tasks were performed by 12 surgeons with varying experience. Performance times and errors were recorded using both 2-dimensional and 3-dimensional vision for each task., Results: Performance time and error rates for all 4 skills confirm a significant advantage using 3-dimensional vision. Performance times were reduced by 34% to 46% using 3-dimensional imaging for all participants with statistical significance. Error rates were reduced by 44% and 66%., Conclusion: Independent of the biomechanical advantages of the da Vinci Robot System, 3-dimensional vision allows for significant improvement in performance times and error rates for both inexperienced residents and advanced laparoscopic surgeons.

Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

Background and Objectives: Goblet cell carcinoid, a rare tumor of intermediate malignant potential, is known to account for a significant minority of appendiceal neoplasms. Sixteen new cases of gastrointestinal goblet cell carcinoid were reviewed to describe their presentation, treatment, and outcome., Methods: A review of 16 cases from a single institution., Results: Sixteen patients were diagnosed with goblet cell carcinoid between 1995 and 2005. Presenting diagnoses included appendicitis (n=8), abdominal or liver mass (n=5), uterine fibroids (n=1), ovarian mass (n=1), and Crohn's Disease exacerbation (n=1). Mean follow-up was 12 months with a mortality of 19% (n=3). Patients were divided into two groups: those where the diagnosis was an incidental finding at operation (Group 1) and those where the presentation was of an abdominal mass or metastatic disease (Group 2). Nine of ten patients in Group 1 initially received appendectomies. Group 2 included patients presenting with Krukenberg type lesions (n=2) and abdominal masses (n=4)., Conclusions: Goblet cell carcinoid is a rare malignant tumor largely affecting the appendix. In patients presenting with appendicitis, our series does not support the recommendation of right hemicolectomy based on pathologic diagnosis alone and surgical intervention must be customized to the individual patient., (Copyright (c) 2006 Wiley-Liss, Inc.)

Purpose: This study was designed to evaluate the management of anastomotic leaks and assess the impact of outpatient leak presentation on clinical outcome., Methods: Thirty-eight patients with clinical anastomotic leaks from 1,684 adult patients undergoing large and small intestinal anastomosis in a tertiary referral center between January 1, 2003 and September 1, 2005 were studied. All pediatric patients and adult patients with esophageal and gastric leaks were excluded. Charts were reviewed for information on anastomotic leak management, discharge status before leak presentation, length of stay, readmissions, and mortality., Results: The overall leak rate was 2.3 percent. Eighty-seven percent of patients (n = 33) were managed operatively. Forty-two percent of patients (n = 16) were discharged after initial operation and presented as outpatients with anastomotic leak. The discharge and inpatient groups were comparable in respect to total length of stay (26.9 vs. 33.4 days) and number of readmissions (2 vs. 1.5). The overall mortality of 5 percent (n = 2) originated from the discharge group. A greater percentage of discharge patients required intensive care unit stays for more than two weeks (25 vs. 14 percent) and very long hospital admissions lasting more than two months (31 vs. 9 percent). A smaller percentage of the discharge group patients had their ostomies reversed (31 vs. 50 percent)., Conclusions: The primary management of clinical anastomotic leak remains intestinal diversion. Although length of stay was shorter in the discharge group, the number of patients who experienced significant intensive care unit stays and very long hospital stays was greater. Within the discharge group, mortality was higher and fewer patients had their ostomies reversed.