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Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse.This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma.This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019.This study was conducted at a single academic tertiary care medical center in the United States.Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected.The transanal total mesorectal excision procedures were performed utilizing a 2-team approach.Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival.Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50-64), and median BMI was 28 kg/m2 (interquartile range, 24.6-32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6-68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6-53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years.Retrospective design, a single center, and relatively short follow-up period were limitations of this study.The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723.ANTECEDENTES:Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema.OBJETIVO:Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto.DISEÑO:Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019.AJUSTE:Centro médico Universitario de atención terciaria único en los Estados Unidos.PACIENTES:Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario.INTERVENCIÓN:Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer.RESULTADOS:Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50-64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6-32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6-68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6-53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años.LIMITACIONES:Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto.CONCLUSIÓN:Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción-Dr. Xavier Delgadillo).

Objective This study sought to prospectively validate an institutional prescribing guideline based on previously defined opioid consumption patterns following inpatient colorectal operations. Background In light of the opioid epidemic, reducing excess prescription quantities is key while still tailoring to patient needs. Methods This is a cohort study of elective colorectal operations (colectomies, proctectomies, and ostomy reversals) at a single tertiary care medical center. Opioid prescribing and consumption patterns (quantified as Equianalgesic 5 mg Oxycodone Pills, EOP) were compared before and after adoption of a tiered opioid prescribing guideline. Tiers were divided based on opioid consumption in the 24-hours prior to discharge: Tier 1 (0 EOP), Tier 2 (0.1-3 EOP), and Tier 3 (>3 EOP). Our guideline recommended maximum prescriptions of 0 EOP for Tier 1, 12 EOP for Tier 2, and 30 EOP for Tier 3. Results The study included 100 patients before and 101 after guideline adoption. Demographic and operative characteristics were similar between cohorts. Guideline adherence was 85%. Overall, there was a 41% reduction in mean prescription quantity and 53% reduction in excess pills per prescription. No change in opioid consumption or refill rates was observed. Conclusion Adoption of a tiered opioid prescribing guideline significantly reduced opioid prescription quantity with no change in consumption or refill rates. Standardization of discharge prescriptions based on patient consumption in the 24-hours prior to discharge may be an important step towards minimizing excess prescribing.

The purpose of this study is to determine the frequency and motivations for medical chaperone use during anorectal exams by colon and rectal surgeons in the outpatient setting. This cross-sectional study examined factors impacting chaperone use via an anonymous online survey distributed via the American Society of Colon and Rectal Surgeons email list. Routine chaperone use was defined as ≥ 90%. Of 1,380 emailed board-certified colon and rectal surgeons, 402 (29.1%) completed the survey in November 2019. Median years in practice was 14, and 72.3% were male. Overall, 65.2% reported routine use of chaperones during anorectal exams. Over half (56.3%) felt chaperones should be mandatory and were more likely to report routine use than those who did not (85.7 vs. 39.1%; p

BACKGROUND Better alignment of opioid prescription quantities with patient need could help reduce excessive prescribing. OBJECTIVE The study sought to develop an institutional prescribing guideline based on defined opioid consumption patterns after inpatient colorectal operations. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a single tertiary care center. PATIENTS Patients who underwent elective major colorectal procedures between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS Patients were categorized into 3 groups based on consumption in the 24-hour period before discharge: tier 1 consumed 0 equianalgesic oxycodone 5-mg pills (n = 53), tier 2 consumed 0.1 to 3.0 equianalgesic oxycodone 5-mg pills (n = 25), and tier 3 consumed >3.0 equianalgesic oxycodone 5-mg pills (n = 22). Average prescription quantity was 17.5 ± 10.5 equianalgesic oxycodone 5-mg pills (range, 0-78). Patients consumed a mean of 6.7 ± 10.9 equianalgesic oxycodone 5-mg pills after discharge and had 10.8 ± 10.2 equianalgesic oxycodone 5-mg pill excess, whereas 51% of patients consumed no pills. Opioid consumption was significantly different between each tier (p < 0.001). A prescribing guideline was developed to satisfy the majority of patients: 0 equianalgesic oxycodone 5-mg pills if tier 1, 12 pills if tier 2, and 30 pills if tier 3. Tiered guideline adoption could reduce prescribed pills by 45% and excess pills per prescription by 73%. Patient history of IBD was independently associated with increased odds of exceeding the guideline (adjusted OR = 7.2 (95% CI, 1.6-32.6)). LIMITATIONS The study was limited by its single-center, retrospective design and that outpatient opioid consumption was self-reported. CONCLUSIONS Following hospital discharge after major colorectal surgery, more than half of patients consumed no opioid pills, and 62% of prescribed opioids were in excess. Outpatient opioid consumption was highly associated with inpatient opioid use in the 24 hours before discharge. Prospective validation of this prescribing guideline is needed, but adoption could reduce excessive prescribing. See Video Abstract at http://links.lww.com/DCR/B575. DESARROLLO DE UNA GUA PRCTICA PARA LA PRESCRIPCIN DE OPIOIDES AL EGRESO DESPUS DE UNA CIRUGA COLORRECTAL MAYOR ANTECEDENTES:Una mejor alineacion de las cantidades de prescripcion de opioides con las necesidades del paciente podria ayudar a reducir la prescripcion excesiva.OBJETIVO:El estudio busco desarrollar una guia institucional de prescripcion basada en patrones definidos de consumo de opioides luego de cirugias colorrectales hospitalarias.DISENO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:El estudio se llevo a cabo en un solo centro de atencion terciaria.PACIENTES:Pacientes que se sometieron a procedimientos colorrectales mayores electivos entre julio de 2018 y enero de 2019.PRINCIPALES MEDIDAS DE RESULTADO:El estudio midio las cantidades de prescripcion y consumo medidas como pildoras de 5 mg de oxicodona equianalgesica (EOP).RESULTADOS:Los pacientes se clasificaron en tres grupos segun el consumo en el periodo de 24 horas antes del egreso: el nivel 1 consumio 0 EOP (n = 53), el nivel 2 consumio 0,1-3 EOP (n = 25) y el nivel 3 consumio mas de 3 EOP (n = 22). La cantidad promedio de prescripcion fue 17,5 (± 10,5) EOP (rango: 0-78). Los pacientes consumieron una media de 6,7 (± 10,9) EOP posterior al egreso y tuvieron un exceso de 10,8 (± 10,2) EOP, mientras que el 51% de los pacientes no consumieron pildoras. El consumo de opioides fue significativamente diferente entre cada nivel (p

BACKGROUND Closer scrutiny of prescription patterns following surgery could contribute to the national effort to combat the opioid epidemic. OBJECTIVE This study aimed to define opioid consumption patterns following anorectal operations for development of an institutional prescribing guideline. DESIGN This was a retrospective cohort study. SETTING The study was conducted at a single tertiary care center. PATIENTS Patients undergoing outpatient anorectal surgery between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS There were 174 operations categorized into 4 operation categories: 72 hemorrhoid excisions, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous operations (14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions). Prescription quantity was varied (range, 3-80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients consumed no pills, 18% consumed all, and 5% required refills. Of total pills prescribed, 63% of were unconsumed. Consumption was significantly different by operation category (average 13.6 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 6.3 after fistula-in-ano operations, 5.8 after condyloma fulguration, and 2.9 after miscellaneous operations; p < 0.001). Home opioid requirements would be met for 80% of patients using the following guideline: 27 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous operations. Guideline adoption would result in a 41% reduction in excess pills per prescription. LIMITATIONS The study was limited by its retrospective, single-center design and because opioid consumption was self-reported. CONCLUSIONS Opioid prescribing patterns and consumption are widely variable after anorectal operations and appear to be highly dependent on the operation category. It is noteworthy that 63% of opioids prescribed after anorectal operations were unused by the patient and may pose a significant public health risk. Based on the usage patterns observed in this study, prospective studies should be performed to optimize opioid prescribing. See Video Abstract at http://links.lww.com/DCR/B374. PATRONES DE CONSUMO DE OPIOIDES DESPUES DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUIA PARA PRESCRIPCION INSTITUCIONAL: Una revision enfocada de los patrones de prescripcion despues de la cirugia podria contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides despues de las operaciones anorrectales para el desarrollo de una guia para prescripcion institucional.Estudio de cohorte retrospectivo.El estudio se realizo en un solo centro de atencion de tercer nivel.pacientes de cirugia anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de pildoras equianalgesicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorias: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones miscelaneas (14 esfinterotomias, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por via transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgesica de 5 mg). En general, el 39% de los pacientes no consumio pildoras, el 18% consumio todo y el 5% requirio equianalgesica adicional. Del total de pildoras recetadas, el 63% no se consumio. El consumo fue significativamente diferente segun la categoria de la operacion (promedio de 13,6 pildoras de oxicodona equianalgesica de 5 mg despues de las hemorroidectomias, 6,3 despues de las operaciones de fistula en el ano, 5,8 despues de la fulguracion del condiloma y 2,9 despues de las operaciones miscelaneas, p

BACKGROUND Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery. OBJECTIVE This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a single tertiary-care institution. PATIENTS Consecutive patients undergoing transanal minimally invasive redo proctectomy were included. INTERVENTIONS Transanal minimally invasive redo proctectomy was performed. MAIN OUTCOME MEASURES The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution. RESULTS Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months. LIMITATIONS This study was limited by its small sample size and its single-institution focus. CONCLUSION For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.

BACKGROUND Discharge to nonhome settings after colorectal resection may increase risk of hospital readmission. OBJECTIVE The purpose of this study was to determine the impact of various discharge dispositions on 30-day readmission after adjusting for confounding demographic and clinical factors. DESIGN This was a retrospective cohort study. SETTINGS Data were obtained from the University HealthSystem Consortium (2011-2015). PATIENTS Adults who underwent elective colorectal resection were included. MAIN OUTCOME MEASURES Thirty-day hospital readmission risk was measured. RESULTS The mean age of the study population (n = 97,455) was 58 years; half were men and 78% were white. Seventy percent were discharged home routinely (home without service), 24% to home with organized health services, 5% to skilled nursing facility, 1% to rehabilitation facility, and

BACKGROUND Online physician rating Web sites are used by over half of consumers to select doctors. No studies have examined physician rating Web sites for colon and rectal surgeons. OBJECTIVE The purpose of this study was to evaluate the accuracy and rating patterns of colon and rectal surgeons on the largest physician rating Web site. DESIGN Physician characteristics and ratings were collected from a randomly selected sample of 500 from 3043 Healthgrades "colon and rectal surgery specialists." Board certifications were verified with the American Board of Surgery and American Board of Colon and Rectal Surgery Web sites. SETTINGS Data acquisition was completed on July 18, 2018. PATIENTS Patients were not directly studied. MAIN OUTCOME MEASURES The primary outcome was to assess the accuracy of Healthgrades in reporting American Board of Surgery and American Board of Colon and Rectal Surgery certification. The secondary outcome was to identify factors associated with high star ratings. RESULTS A total of 48 (9.6%) of the 500 sampled were incorrectly identified as practicing US surgeons and excluded from subsequent analysis. Healthgrades showed 80.1% agreement with verified board certifications for American Board of Surgery and 85.4% for American Board of Colon and Rectal Surgery. The mean star rating was 4.2 of 5.0 (SD = 0.9), and 77 (21.6%) had 5-star ratings. In a multivariable logistic model (p 40 years in practice (OR = 3.35; p = 0.04) and fewer reviews (OR = 0.88; p < 0.001). There were no significant associations with surgeon sex, age, geographic region, or board certification. LIMITATIONS Data were limited to a single physician rating Web site. CONCLUSIONS In the modern age of healthcare consumerism, physician rating Web sites should be used with caution given inaccuracies. More accurate online resources are needed to inform patient decisions in the selection of specialized colon and rectal surgical care. See Video Abstract at http://links.lww.com/DCR/B91. PRECISION DE DATOS Y PREDICTORES DE ALTAS CALIFICACIONES DE CIRUJANOS DE COLON Y RECTO EN UN SITIO WEB DE CALIFICACION MEDICA EN LINEA: Mas de la mitad de los consumidores utilizan los sitios web de calificacion de medicos en linea para seleccionar medicos. Ningun estudio ha examinado los sitios web de calificacion de medicos para cirujanos de colon y recto.Evaluar la precision y los patrones de calificacion de los cirujanos de colon y recto en el sitio web mas grande de calificacion de medicos.Las caracteristicas y calificaciones de los medicos se obtuvieron de una muestra seleccionada al azar de 500 de 3,043 "especialistas en cirugia de colon y recto" de Healthgrades. Las certificaciones del Consejo se verificaron en los sitios web del Consejo Americano de Cirugia y del Consejo Americano de Cirugia de Colon y Recto.La adquisicion de datos se completo el 18 de julio de 2018.Los pacientes no fueron estudiados directamente.El resultado primario fue evaluar la precision de Healthgrades al informar la certificacion por el Consejo Americano de Cirugia y por el Consejo Americano de Cirugia de Colon y Recto. El resultado secundario fue identificar factores asociados con altas calificaciones en estrellas.Un total de 48 (9.6%) de la muestra de 500 fueron identificados incorrectamente como cirujanos practicantes de EE. UU. y excluidos del analisis subsecuente. Healthgrades mostro un 80.1% de concordancia con las certificaciones verificadas del Consejo Americano de Cirugia y el 85.4% con el Consejo Americano de Cirugia de Colon y Recto. La calificacion promedio de estrellas fue 4.2 / 5 (SD 0.9), y 77 (21.6%) tuvieron calificaciones de 5 estrellas. En un modelo logistico multivariable (p

Comprehensive and multidisciplinary care are critical in rectal cancer treatment. We sought to determine if completeness of preoperative care was associated with pathologic specimen quality and postoperative morbidity.Clinical stage I-III rectal adenocarcinoma patients who underwent elective low anterior resection or abdominoperineal resection were identified from the 2016-2017 American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. The 3 preoperative NSQIP variables (colonoscopy, stoma marking, and neoadjuvant chemoradiation) were used to divide patients into 2 cohorts: complete vs incomplete preoperative care. The primary outcome was a composite higher pathologic specimen quality score (12 lymph nodes, negative circumferential, and negative distal margins). The secondary outcome was 30-day morbidity. Preoperative characteristics were compared with ANOVAs and chi-square tests. Outcomes measures were evaluated with logistic regression.We identified 1,125 patients: 591 (52.5%) complete and 534 (47.5%) incomplete. The complete group was younger, had more women, lower-third rectal tumors, clinical stage III disease, and neoadjuvant treatment. The complete group had higher odds of better pathologic specimen quality after adjusting for age, sex, tumor location, stage, and neoadjuvant therapy (adjusted odds ratio [aOR] 1.75, p = 0.001). The complete group had decreased rates of transfusions (odds ratio [OR] 0.47, p0.001), postoperative ileus (OR 0.67, p = 0.01), sepsis (OR 0.32, p = 0.01), and readmissions (OR 0.60, p = 0.003). Other complications did not statistically differ between groups.Complete preoperative care in rectal adenocarcinoma is associated with higher pathologic specimen quality and reduced postoperative morbidity. This highlights the importance of adherence to guideline-directed care.

Background Almost a decade after international guidelines defining anastomotic leak (AL) were published, the definition of AL remains inconsistent. Methods A 3-round modified Delphi study was conducted among a national panel of 8 surgeon experts to assess consensus related to the definition of AL following colorectal resection. Consensus was defined when a scenario was rated as very important or absolutely essential by at least 85% of the experts in round 3. Results Seven of fifteen (47%) clinical and radiological scenarios of AL achieved consensus. 80% of clinical scenarios reached consensus. 30% of radiological scenarios reached consensus including CT demonstrating air bubbles around the anastomosis. No consensus was achieved in 70% of radiological scenarios. Conclusions Consensus on the definition of AL is difficult to reach, in relation to international guidelines; which implies that further refinement of the definition of AL is needed to compare patient outcomes.

Trends and distribution of ileal pouch-anal anastomosis (IPAA) procedures for patients with ulcerative colitis (UC) are unknown. We examined the frequency, distribution, and volume-outcome relationship for this relatively infrequent procedure using a large national data source. Data were obtained from the University HealthSystem Consortium (UHC) for patients with a primary diagnosis of UC admitted electively and who underwent surgical intervention between 2012 and 2015. The mean age of the study population (n = 6875) was 43 years and 57% were men. Among these, one-third (n = 2307) underwent an IPAA, while 24% (n = 1160) underwent total abdominal colectomy, 16% (n = 1134) underwent proctectomy, and 2% (n = 108) underwent total proctocolectomy with end ileostomy. The frequency of IPAA cases among all elective surgical cases was relatively stable at 33–35% over the study period. A total of 131 hospitals, out of 279 hospitals participating in the UHC (47%), performed IPAA. UHC contains all inpatient data on more than 140 (> 90%) academic medical centers in the US and their affiliates. Most hospitals (101) performed < 5 cases annually. The median number of IPAA cases performed annually was 1.8 [IQR 0.8 – 4.3]. The top 10 hospitals performed one-half (48%) of IPAA cases, but only 18% of another type of complex pelvic dissection cases such as low anterior resection. Short-term postoperative complications after IPAA, however, were similar regardless of IPAA volume. Nearly one-half of IPAA cases were performed at only 10 hospitals out of the 131 hospitals performing IPAA in the study. IPAA procedures are infrequently performed by most academic medical centers in the US. The redistribution of IPAA procedures, likely a result of previously established referral patterns and centralization, has a potential impact on the training of future colorectal fellows as well as access to care.

INTRODUCTION Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery. TECHNIQUE We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy. RESULTS The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound. CONCLUSION We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.

Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher's exact and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications.85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51-65), and median BMI of 28 (IQR: 24-32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49-6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6-12.4, p 0.05) after adjusting for gender.Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.

The purpose of this study is to determine the frequency and motivations for medical chaperone use during anorectal exams by colon and rectal surgeons in the outpatient setting.This cross-sectional study examined factors impacting chaperone use via an anonymous online survey distributed via the American Society of Colon and Rectal Surgeons email list. Routine chaperone use was defined as ≥ 90%.Of 1,380 emailed board-certified colon and rectal surgeons, 402 (29.1%) completed the survey in November 2019. Median years in practice was 14, and 72.3% were male. Overall, 65.2% reported routine use of chaperones during anorectal exams. Over half (56.3%) felt chaperones should be mandatory and were more likely to report routine use than those who did not (85.7 vs. 39.1%; p 0.001). Only 23.7% reported that their institutions had formal chaperone policies. The most common reason for use was medicolegal (91.8%), and the most common barrier was chaperone availability (56.7%). When chaperones were used, 42% did not document use in the medical record. On multivariable analysis, increased odds of routine chaperone use were independently associated with: being ≤ 10 years in practice, routine chaperone use during fellowship, and chaperones being routinely available.Half of surgeons felt that chaperones should be mandatory, suggesting lack of consensus among the cohort. Despite expressing legal concerns, one-third did not use chaperones and nearly half who used chaperones did not document their use. Efforts to improve chaperone availability, documentation of chaperone use, and knowledge of policies are necessary.

Readmissions reflect adverse patient outcomes, and clinicians currently lack accurate models to predict readmission risk.We sought to create a readmission risk calculator for use in the postoperative setting after elective colon and rectal surgery.Patients were identified from 2012-2014 American College of Surgery-National Surgical Quality Improvement Program data. A model was created with 60% of the National Surgical Quality Improvement Program sample using multivariable logistic regression to stratify patients into low/medium- and high-risk categories. The model was validated with the remaining 40% of the National Surgical Quality Improvement Program sample and 2016-2018 institutional data.The study included both national and institutional data.Patients who underwent elective abdominal colon or rectal resection were included.The primary outcome was readmission within 30 days of surgery. Secondary outcomes included reasons for and time interval to readmission.The model discrimination (c-statistic) was 0.76 ((95% CI, 0.75-0.76); p0.0001) in the National Surgical Quality Improvement Program model creation cohort (n = 50,508), 0.70 ((95% CI, 0.69-0.70); p0.0001) in the National Surgical Quality Improvement Program validation cohort (n = 33,714), and 0.62 ((95% CI, 0.54-0.70); p = 0.04) in the institutional cohort (n = 400). High risk was designated as ≥8.7% readmission risk. Readmission rates in National Surgical Quality Improvement Program and institutional data were 10.7% and 8.8% overall; of patients predicted to be high risk, observed readmission rate was 22.1% in the National Surgical Quality Improvement Program and 12.4% in the institutional cohorts. Overall median interval from surgery to readmission was 14 days in the National Surgical Quality Improvement Program and 11 days institutionally. The most common reasons for readmission were organ space infection, bowel obstruction/paralytic ileus, and dehydration in both the National Surgical Quality Improvement Program and institutional data.This was a retrospective observational review.For patients who undergo elective colon and rectal surgery, use of a readmission risk calculator developed for postoperative use can identify high-risk patients for potential amelioration of modifiable risk factors, more intensive outpatient follow-up, or planned readmission. See Video Abstract at http://links.lww.com/DCR/B284. CREACIÓN Y VALIDACIÓN INSTITUCIONAL DE UNA CALCULADORA DE RIESGO DE REINGRESO PARA CIRUGÍA COLORRECTAL ELECTIVE: Los reingresos reflejan resultados adversos de los pacientes y los médicos actualmente carecen de modelos precisos para predecir el riesgo de reingreso.Intentamos crear una calculadora de riesgo de readmisión para su uso en el entorno postoperatorio después de una cirugía electiva de colon y recto.Los pacientes que se sometieron a una resección electiva del colon abdominal o rectal se identificaron a partir de los datos del Programa Nacional de Mejora de la Calidad Quirúrgica (ACS-NSQIP) del Colegio Americano de Cirugia Nacional 2012-2014. Se creó un modelo con el 60% de la muestra NSQIP utilizando regresión logística multivariable para estratificar a los pacientes en categorías de riesgo bajo / medio y alto. El modelo fue validado con el 40% restante de la muestra NSQIP y datos institucionales 2016-2018.El estudio incluyó datos tanto nacionales como institucionales.El resultado primario fue el reingreso dentro de los 30 días de la cirugía. Los resultados secundarios incluyeron razones e intervalo de tiempo para el reingreso.La discriminación del modelo (estadística c) fue de 0,76 (IC del 95%: 0,75-0,76, p0,0001) en la cohorte de creación del modelo NSQIP (n = 50,508), 0,70 (IC del 95%: 0,69-0,70, p0,0001) en la cohorte de validación NSQIP (n = 33,714), y 0,62 (IC del 95%: 0,54-0,70, p = 0,04) en la cohorte institucional (n = 400). Alto riesgo se designó como8,7% de riesgo de readmisión. Las tasas de readmisión en NSQIP y los datos institucionales fueron del 10,7% y del 8,8% en general; de pacientes con riesgo alto, la tasa de reingreso observada fue del 22.1% en el NSQIP y del 12.4% en las cohortes institucionales. El intervalo medio general desde la cirugía hasta el reingreso fue de 14 días en NSQIP y 11 días institucionalmente. Las razones más comunes para el reingreso fueron infección del espacio orgánico, obstrucción intestinal / íleo paralítico y deshidratación tanto en NSQIP como en datos institucionales.Esta fue una revisión observacional retrospectiva.Para los pacientes que se someten a cirugía electiva de colon y recto, el uso de una calculadora de riesgo de reingreso desarrollada para el uso postoperatorio puede identificar a los pacientes de alto riesgo para una posible mejora de los factores de riesgo modificables, un seguimiento ambulatorio más intensivo o un reingreso planificado. Consulte Video Resumen en http://links.lww.com/DCR/B284. (Traducción-Dr Yesenia Rojas-Khalil).

To examine patterns of Twitter use by surgery departments with residency programs and understand relevant motivations and concerns. The primary outcome was to quantify account prevalence and activity. The secondary outcomes were to identify reasons for use and perceived benefits and concerns.A cross-sectional study was performed on Twitter accounts of departments of surgery with Accreditation Council of Graduate Medical Education accredited general surgery residencies. An anonymous survey was distributed to all programs with accounts. Data acquisition was completed in August 2019 and analysis was completed in February 2020.Among the 319 departments of surgery, only 80 (25%) had department of surgery Twitter accounts. Mean account age was 3.5 years (range: 0-9.8), with the highest account creation in 2017 (n = 23, 29%). Median total tweets per account was 314 (range 3-21,893), and median number of followers was 454 (range 18-22,353). Having a Twitter account was associated with program type: 66/123 (54%) university-based, 1/9 (11%) military, 13/124 (11%) community/university-affiliated, and 0/63 (0%) community (p0.01). Survey response rate was 40% (n = 32). Only 59% had formal posting guidelines. Daily logins (78%) and daily tweeting (53%) were common. The most frequent perceived benefits were "highlighting new research and major events" (97%), "increasing visibility within the academic community" (91%), and "improving resident engagement" (75%). The most common concerns were "professionalism" (72%), "privacy" (63%), and "time commitment" (53%).Though only a quarter of departments of general surgery had Twitter accounts, they were felt to be key for improving academic reach. Formal posting guidelines existed for 59% of survey respondents, although concerns about privacy and content were common. An underutilized tool for surgery departments to promote academic achievements, Twitter use represents a potential opportunity to engage the surgical community more broadly.

Carbon dioxide (CO2) embolism is a rare but potentially devastating complication of minimally invasive abdominal and retroperitoneal surgery. Characterized by a decrease in end-tidal CO2 (ETCO2) and oxygen saturation (SpO2), CO2 emboli can cause rapid intraoperative hypotension and cardiovascular collapse. Transanal total mesorectal excision (taTME) is a novel surgical approach for rectal resection, which requires high flow CO2 insufflation in a low volume operative field. In this setting, the incidence of CO2 embolism is unknown; we evaluate three cases of intraoperative CO2 embolism that occurred during the transanal portion of the TME dissection. All taTME cases from December 2014 to March 2018 at a single institution were reviewed. Cases of CO2 embolism were identified intraoperatively and characterized using the operative reports and anesthesia records. The transanal/pelvic insufflation included a targeted pressure of 15 mm Hg, high flow and high smoke evacuation. Physiologic derangements and management of these instances were analyzed. The postoperative course was evaluated and any complications were noted. A total of 80 taTME were performed for benign and malignant disease. Three patients (4%) developed intraoperative evidence of CO2 embolism. Each instance occurred during the transanal portion of the dissection. Physiologic changes were marked by abrupt decrease in end-tidal ETCO2, SpO2, and blood pressure (BP). Management included immediate release of pneumopelvis, hemodynamic support with crystalloid or vasopressors, and placement of the patient in the Trendelenburg position with left side down. Within 10 min of the acute event, all patients had return of ETCO2, SpO2, and BP to pre-event levels. There were no intraoperative or postoperative sequelae including arrhythmia, myocardial infarction, stroke or death. No cases required conversion to open. During taTME, rare CO2 emboli may occur in the setting of venous bleeding during pneumopelvis, causing sudden, transient cardiovascular instability. Immediate recognition of rapid decrease in ETCO2, SpO2, and BP should be followed by desufflation of pneumopelvis, patient positioning in Trendelenburg and left lateral decubitus, and hemodynamic support. Increased awareness of this potential complication and maintaining a high index of suspicion will lead to preparedness of the anesthesia and surgery teams.

Following FDA approval, robotic-assisted colorectal surgery (RACS) has increased in prevalence. We aimed to identify trends in utilization and patient characteristics of RACS in the United States using the University HealthSystem Consortium database between October 2011–September 2015. Outcome measures were number and percentage of procedures performed with robotic-assistance. 7100 patients were identified. The most common procedures were low anterior resection, sigmoid colectomy, abdominoperineal resection, right colectomy, rectopexy, left colectomy, and total colectomy. There was a 158% increase in RACS procedures. As a percentage of all approaches, RACS increased from 2.6% to 6.6%. The number of centers performing RACS increased from 105 to 140. Over the study period, the complexity of patients increased, with the percentage of patients with ≥3 comorbidities rising from 18% to 24% (p = 0.03) and patients with a moderate severity of illness score increasing from 35% to 41% (p = 0.04). RACS has expanded significantly in volume, number of centers, and patient selection. Further studies evaluating outcomes and cost of RACS are required to determine whether these increases are justified by improved clinical outcomes.

Anastomotic leaks (AL) after ileal pouch procedure occur in 4-17% of cases and can lead to pelvic sepsis, stricture, delayed ileostomy closure and pouch failure [1]. Redo-pelvic surgery can be technically demanding and is associated with major postoperative morbidity in 16% of case.[2]. Weidenhagen first described the use of endoluminal vacuum-assisted therapy (E-VAT) for anastomotic leak [3]. Gardenbroek et al showed using E-VAT followed by open transanal surgical closure of the defect in patients with IPAA and AL can improve outcomes by reducing the anastomotic healing time [4].

Trends and distribution of ileal pouch-anal anastomosis (IPAA) procedures for patients with ulcerative colitis (UC) are unknown. We examined the frequency, distribution, and volume-outcome relationship for this relatively infrequent procedure using a large national data source.Data were obtained from the University HealthSystem Consortium (UHC) for patients with a primary diagnosis of UC admitted electively and who underwent surgical intervention between 2012 and 2015.The mean age of the study population (n = 6875) was 43 years and 57% were men. Among these, one-third (n = 2307) underwent an IPAA, while 24% (n = 1160) underwent total abdominal colectomy, 16% (n = 1134) underwent proctectomy, and 2% (n = 108) underwent total proctocolectomy with end ileostomy. The frequency of IPAA cases among all elective surgical cases was relatively stable at 33-35% over the study period. A total of 131 hospitals, out of 279 hospitals participating in the UHC (47%), performed IPAA. UHC contains all inpatient data on more than 140 (90%) academic medical centers in the US and their affiliates. Most hospitals (101) performed5 cases annually. The median number of IPAA cases performed annually was 1.8 [IQR 0.8 - 4.3]. The top 10 hospitals performed one-half (48%) of IPAA cases, but only 18% of another type of complex pelvic dissection cases such as low anterior resection. Short-term postoperative complications after IPAA, however, were similar regardless of IPAA volume.Nearly one-half of IPAA cases were performed at only 10 hospitals out of the 131 hospitals performing IPAA in the study. IPAA procedures are infrequently performed by most academic medical centers in the US. The redistribution of IPAA procedures, likely a result of previously established referral patterns and centralization, has a potential impact on the training of future colorectal fellows as well as access to care.

Racial disparities in outcomes are well described among surgical patients.The purpose of this work was to identify any racial disparities in the receipt of a minimally invasive approach for colorectal surgery.Adults undergoing colorectal surgery were studied using the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify predictors for the receipt of a minimally invasive approach.The study was conducted at academic hospitals and their affiliates.Adults ≥18 years of age who underwent surgery for colorectal cancer, diverticular disease, IBD, or benign colorectal tumor between 2008 and 2011 were included.The receipt of a minimally invasive surgical approach was the main measured outcome.A total of 82,474 adult patients met the study inclusion criteria. Of these, 69,664 (84%) were white, 10,874 (13%) were black, and 1936 (2%) were Asian. Blacks were younger, with higher rates of public insurance and higher comorbidity burden and baseline severity of illness compared with white and Asian patients. Black patients were less likely (adjusted OR = 0.83 (95% CI, 0.79-0.87)) and Asian patients more likely (adjusted OR = 1.34 (95% CI, 1.21-1.49)) than whites to receive minimally invasive surgery. This association did not change with stratification by insurance type (public or private). Black patients had higher rates of intensive care unit admission and nonhome discharge, as well as an increased length of stay compared with white and Asian patients. No differences in complications, readmission, or mortality rates were observed with minimally invasive surgery, but black patients were more likely to be readmitted or to die with open surgery.The study was limited by the retrospective nature of its data.We identified racial differences in the receipt of a minimally invasive approach for colorectal surgery, regardless of insurance status, as well as improved outcomes for minority races who underwent a minimally invasive technique compared with open surgery. The improved outcomes associated with minimally invasive surgery should prompt efforts to increase rates of its use among black patients.

There is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery. Patients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS). A total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26–1.81), ICU stays (OR 1.25, 95 % CI 1.03–1.51), and longer LOS (+1.67 days, 95 % CI 1.21–2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications. In patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.

BACKGROUND Hospital readmissions after elective colectomy are costly and potentially preventable. It is unknown whether hospital discharge on a weekend impacts readmission risk. OBJECTIVE This study aimed to use a national database to determine whether discharge on a weekend versus weekday impacts the risk of readmission, and to determine what discharge-related factors impact this risk. DESIGN This investigation is a retrospective cohort study. SETTINGS Data were derived from the University HealthSystem Consortium, PATIENTS:: Adults who underwent elective colectomy from 2011 to 2015 were included. MAIN OUTCOME MEASURES The primary outcome measured was the 30-day hospital readmission rate. RESULTS Of the 76,031 patients who survived the index hospitalization, the mean age of the study population was 58 years; half were men and more than 75% were white. Overall, 20,829 (27%) were discharged on the weekend, and the remaining 55,202 (73%) were discharged on weekdays. The overall 30-day readmission rate was 10.5%; 8.9% for those discharged on the weekend vs 11.1% for those discharged during the weekday (unadjusted OR, 0.78; 95% CI, 0.74-0.83). The adjusted readmission risk was lower for patients discharged home without services (routine, without organized home health service) on a weekend compared with on a weekday (adjusted OR, 0.87; 95% CI, 0.81-0.93; readmission rates, 7.4% vs 8.9%, p < 0.001); however, the combination of weekend discharge and the need for home services increased readmission risk (adjusted OR, 1.39; 95% CI, 1.25-1.55; readmission rate, 16.2% vs 8.9%, p < 0.001). Although patients discharged to rehabilitation and skilled nursing facilities were at an increased risk of readmission compared with those discharged to home, there was no additive increase in risk of readmission for weekend discharge. LIMITATIONS Data did not capture readmission beyond 30 days or to nonindex hospitals. CONCLUSIONS Patients discharged on a weekend following elective colectomy were at increased risk of readmission compared with patients discharged on a weekday if they required organized home health services. Further prospective studies are needed to identify areas of intervention to improve the discharge infrastructure. See Video Abstract at http://links.lww.com/DCR/A799.

Volume has been shown to be an important determinant of quality and cost outcomes.We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

Short-term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States.The aim of this study is to describe outcomes after the initiation of a transanal total mesorectal excision program in the setting of an academic colorectal training program.This is a single-center retrospective review of consecutive patients who underwent transanal total mesorectal excision from December 2014 to August 2016.This study was conducted at an academic center with a colorectal residency program.Patients with benign and malignant diseases were selected.All transanal total mesorectal excisions were performed with abdominal and perineal teams working simultaneously.The primary outcomes measured were pathologic quality, length of hospital stay, 30-day morbidity, and 30-day mortality.There were 40 patients (24 male). The median age was 55 years (interquartile range, 46.7-63.4) with a median BMI of 29 kg/m (interquartile range, 24.6-32.4). The primary indication was cancer (n = 30), and tumor height from the anal verge ranged from 0.5 to 15 cm. Eighty percent (n = 24) of the patients who had rectal cancer received preoperative chemoradiation. The most common procedures were low anterior resection (67.5%), total proctocolectomy (15%), and abdominoperineal resection (12.5%). Median operative time was 380 minutes (interquartile range, 306-454.4), with no change over time. For patients with malignancy, the mesorectum was complete or nearly complete in 100% of the specimens. A median of 14 lymph nodes (interquartile range, 12-17) were harvested, and 100% of the rectal cancer specimens achieved R0 status. Median length of stay was 4.5 days (interquartile range, 4-7), and there were 6 readmissions (15%). There were no deaths or intraoperative complications.This study's limitations derive from its retrospective nature and single-center location.A transanal total mesorectal excision program can be safely implemented in a major academic medical center. Quality outcomes and patient safety depend on a comprehensive training program and a coordinated team approach. See Video Abstract at http://links.lww.com/DCR/A448.

BACKGROUND After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. OBJECTIVE The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery. DESIGN Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery. SETTINGS This study was conducted at an academic hospital and its affiliates. PATIENTS Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study. MAIN OUTCOME MEASURES Readmission within 30 days of index discharge was the main outcome measured. RESULTS A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53-3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher ($26,917 vs $13,817; p < 0.001) for readmitted than for nonreadmitted patients. LIMITATIONS Follow-up was limited to 30 days after initial discharge. CONCLUSIONS Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

Background The incidence and virulence of Clostridium difficile infection (CDI) are on the rise. The characteristics of patients who develop CDI following colorectal resection have been infrequently studied. Materials and methods We utilized the University HealthSystem Consortium database to identify adult patients undergoing colorectal surgery between 2008 and 2012. We examined the patient-related risk factors for CDI and 30-day outcomes related to its occurrence. Results A total of 84,648 patients met our inclusion criteria, of which the average age was 60 years and 50% were female. CDI occurred in 1,266 (1.5%) patients during the years under study. The strongest predictors of CDI were emergent procedure, inflammatory bowel disease (IBD), and major/extreme APR-DRG severity of illness score. CDI was associated with a higher rate of complications, intensive care unit (ICU) admission, longer preoperative inpatient stay, 30-day readmission rate, and death within 30 days compared to non-CDI patients. Cost of the index stay was, on average, $14,130 higher for CDI patients compared with non-CDI patients. Conclusion Emergent procedures, higher severity of illness, and inflammatory bowel disease are significant risk factors for postoperative CDI in patients undergoing colorectal surgery. Once established, CDI is associated with worse outcomes and higher costs. The poor outcomes of these patients and increased costs highlight the importance of prevention strategies targeting high-risk patients.

BACKGROUND: Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. STUDY DESIGN: Weperformedaretrospectivestudyofpatientswhounderwentresectionforcoloncancer,using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. RESULTS: Atotalof17,749patientswereincludedinthisstudy.Theaverageageofthecohortwas65yearsand 51%ofpatientswerefemale.Afteradjustmentforpotentialconfounders,comparedwithLVS,HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS,OR1.1695%CI1.65,1.26).Postoperativecomplicationsweresignificantlylowerinpatients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were $927 (95% CI -$1,567 to -$287) lower in the HVS group compared with the LVS group. CONCLUSIONS: Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association. (J Am Coll Surg 2014;218:1223e1230. � 2014 by the American College of Surgeons)

Routine splenic flexure mobilization (SFM) has been previously recommended to ensure an adequate length for a tension free anastomosis during resection for diverticulitis. We sought to evaluate the role of selective SFM for diverticulitis, and its impact on outcomes.Retrospective review of elective colectomies at a tertiary care center (2007-2015) for left-sided diverticulitis were identified from the National Surgical Quality Improvement Program. Demographics and perioperative characteristics were compared; and 30-day risk-adjusted outcomes were assessed.We identified 208 sigmoid/left colectomy cases. A laparoscopic approach predominated (71%), and SFM was performed in 54% of cases (n = 113). Demographics and comorbidities were similar. Median operative time was greater in the SFM group [226; interquartile range (IQR): (190-267) minutes] compared to no mobilization [180; IQR: (153-209) minutes] (p 0.01). After risk adjustment, SFM was associated with a trend towards an increased rate of a minor morbidity (OR: 2.8; p = 0.05).Splenic flexure mobilization was performed selectively in half of colectomies evaluated. This technique was associated with a trend towards an increased rate of minor complications, with no difference in major adverse events, including organ space infections. These findings suggest that for patient with diverticulitis, SFM should be performed in an individualized fashion.

Harmonic Scalpel(R) hemorrhoidectomy (HSH) is an established surgical therapy for the treatment of symptomatic grade III and IV hemorrhoids. Hemorrhoid surgery is still being performed as an inpatient procedure with general or regional anesthesia in many centers today. There was a trend toward performing hemorrhoid surgery as an ambulatory procedure using local anesthesia supplemented with intravenous sedation. The aim of the current study was to evaluate the safety and efficacy of HSH performed with combination local anesthesia and intravenous sedation in an ambulatory surgical center.A retrospective review was performed on the clinical charts of all patients undergoing HSH in an ambulatory surgical center from 2001 to 2005. All hemorrhoidectomies were attempted under propofol/ketamine intravenous sedation and local anesthesia in the prone position. A simple, open technique without routine suture was used.During the study period, 180 patients (70 females) underwent HSM. Mean procedure and total operating room time were 12 and 28 min, respectively. One patient (0.6%) was converted to general endotracheal anesthesia. Ten patients (5.6%) required post anesthesia care unit (PACU) observation. All patients were discharged home after the procedure. Postoperative complications occurred in 19 patients (10.6%). There were no reoperations and the total readmission rate was 3.7%.HSH performed with a combination of intravenous sedation and local anesthesia is safe and effective in the ambulatory surgery setting. The combined technique was associated with a rate of complications comparable to published series utilizing conventional hemorrhoidectomy techniques. Added benefits include shorter hospital stay and a potential for cost savings.

Introduction: Pre-operative restaging CT scans are often performed routinely following neoadjuvant chemoradiotherapy for locally advanced rectal cancer. There is a paucity of data on the utility of this common practice. We sought to determine how often restaging CTs identified disease progression or regression that altered management. Methods: We performed a single-institution retrospective study. From 2007 to 2011, 182 patients had newly-diagnosed, non-metastatic rectal adenocarcinoma, of which 96 were surgical candidates with clinical stage II/III disease. Ninety-one of these patients (95%) completed neoadjuvant chemoradiation. Results: Eighty-three out of 91 patients (91%) had restaging CTs. Four patients (5%) had new lesions suspicious for distant metastasis (2 lung, 2 liver) on restaging CT scan reports (1 of these was present on initial staging CT but not reported). All 4 patients had node-positive disease. In no case did restaging CT result in a change in surgical management. Discussion: Because of the financial costs and established risks of intravenous contrast and cumulative radiation exposure, it may be advisable to take a more selective approach to preoperative imaging. Larger, prospective studies may enable identification of an at-risk cohort who would benefit most from restaging CT. Conclusion: Routine restaging CT scans are low yield in the management of locally advanced rectal cancer.

Diverticular disease ranks as one of the more common gastrointestinal disorders among westernized nations. Few studies have examined racial differences in the care and surgical outcomes of diverticulitis. The aim of this study was to determine if race is a predictor of peri-operative morbidity and mortality following surgery for diverticulitis. The American College of Surgeons National Surgical Quality Improvement Program (2005–2008) was queried with the primary dependent variables being 30-day morbidity and mortality. Differences in morbidity and mortality between races were compared using χ 2 and Student t tests. Logistic regression was used to calculate odds ratios for morbidity and mortality. To determine if the effect of race is modified by insurance status and case complexity, additional models were developed across age subgroups (

Purpose Patients with inflammatory bowel disease are often at highest risk for surgical site infections. We sought to define the predictors of surgical site infections and to develop a risk score for predicting those at highest risk. Methods Patients undergoing a bowel resection for Crohn's disease or ulcerative colitis were identified from National Surgical Quality Improvement Program 2008. Univariate and multivariate analyses were conducted to identify predictors of surgical site infections. Clinically relevant prediction categories were developed and the predictive behavior of the model was validated by use of National Surgical Quality Improvement Program 2007. An integer-based scoring system risk score was created proportional to the logistic regression coefficients, grouping patients into categories of similar risk. Results We identified 271,368 patients; 3981 of these patients underwent an operation for Crohn's disease (n = 2895) or ulcerative colitis (n = 1086). Nine hundred (22.6%) patients developed surgical site infections. Predictors included weight loss, smoking, emergent surgery, wound class, operative time (minutes), and an ASA score >2. A risk score was developed by stratifying patients into low (0-5), 15.6%; medium (6-8), 25.2%; and high (>8), 36.1% risk. Conclusions Patients with inflammatory bowel disease are at high risk for surgical site infections. Preoperative factors including weight loss, smoking, emergent surgery and an ASA score >2 are strong predictors of surgical site infections. Operative time and wound class are important intraoperative predictors. A risk score, based on pre- and intraoperative variables, can be used to identify patients at highest risk of developing surgical site infections. This may allow for appropriate process measures to be implemented to prevent and lessen the impact of surgical site infections in this high-risk population.

S A T A b st ra ct s performed. Results: A total of 78 paired CRC and normal tissue specimens (36 M/ 42 F, age 67+/-14.5) were assessed (88% colon, 12% rectal; pathologic stage 2, 44; stage 3, 34). In 65% of tumors the IMP3 expression levels were at least 0.1% of the testes level and, also, the tumor to normal tissue IMP3 expression ratio was greater than 1. IHC was carried out on 46 paired tumor and normal tissue sections; IMP3 staining was noted in 50% of the tumor sections (1+ to 3+ intensity) and in 5% of the normal tissue sections (1+ to 2+). Non-significant increases in IMP3 expression levels were noted in the Stage 3 and node positive tumors. The median tumor expression level was higher in women (p=0.036). Discussion: The majority of CRC tumors expressed IMP3 as judged by RT-PCR and IHC. This is in distinction to the low CRC expression levels noted for other CT proteins in previous studies. A larger and more diverse group of tumors (Stage 1-4) needs to be assessed to determine if IMP3 expression correlates with T, N, or final tumor stage. Assessment of blood for anti-IMP3 antibodies and IMP3 protein is also needed. IMP3 holds some promise as a vaccine target.