Development of a Practice Guideline for Discharge Opioid Prescribing After Major Colorectal Surgery.

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 alineación de las cantidades de prescripción de opioides con las necesidades del paciente podría ayudar a reducir la prescripción excesiva.OBJETIVO:El estudio buscó desarrollar una guía institucional de prescripción basada en patrones definidos de consumo de opioides luego de cirugías colorrectales hospitalarias.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:El estudio se llevó a cabo en un solo centro de atención 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 midió las cantidades de prescripción y consumo medidas como píldoras de 5 mg de oxicodona equianalgésica (EOP).RESULTADOS:Los pacientes se clasificaron en tres grupos según el consumo en el período de 24 horas antes del egreso: el nivel 1 consumió 0 EOP (n = 53), el nivel 2 consumió 0,1-3 EOP (n = 25) y el nivel 3 consumió más de 3 EOP (n = 22). La cantidad promedio de prescripción 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 píldoras. El consumo de opioides fue significativamente diferente entre cada nivel (p <0,001). Se desarrolló una guía de prescripción para satisfacer a la mayoría de los pacientes: 0 EOP del nivel 1, 12 EOP del nivel 2 y 30 EOP del nivel 3. La adquisición de una guía escalonada podría reducir las píldoras recetadas en un 45% y el exceso de píldoras por receta en un 73%. El historial del paciente de enfermedad inflamatoria intestinal se asoció de forma independiente con un aumento de las probabilidades de superar la guía (ORa 7,2; IC del 95%: 1,6-32,6).LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro y por el consumo de opioides del paciente ambulatorio el cual fue autoinformado.CONCLUSIONES:Tras el egreso hospitalario de una cirugía colorrectal mayor, más de la mitad de los pacientes no consumieron pastillas opioides y el 62% de los opioides prescritos estaban en exceso. El consumo de opioides como paciente ambulatorio estuvo altamente asociado con el uso de opioides como paciente hospitalizado en las 24 horas previas al egreso. Se necesita una validación prospectiva de esta guía de prescripción, pero la adopción podría reducir la prescripción excesiva. Consulte Video Resumen en http://links.lww.com/DCR/B575.

Defining Anastomotic Leaks After Colorectal Surgery: Results of a National Survey.

BACKGROUND: Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist. MATERIALS AND METHODS: A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery. RESULTS: Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak. CONCLUSIONS: These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

Transanal Minimally Invasive Surgery: An Effective Approach for Patients Who Require Redo Pelvic Surgery for Anastomotic Failure.

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.

Opioid Consumption Patterns After Anorectal Operations: Development of an Institutional Prescribing Guideline.

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 DESPUÉS DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUÍA PARA PRESCRIPCIÓN INSTITUCIONAL: Una revisión enfocada de los patrones de prescripción después de la cirugía podría contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides después de las operaciones anorrectales para el desarrollo de una guía para prescripción institucional.Estudio de cohorte retrospectivo.El estudio se realizó en un solo centro de atención de tercer nivel.pacientes de cirugía anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de píldoras equianalgésicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorías: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones misceláneas (14 esfinterotomías, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por vía transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgésica de 5 mg). En general, el 39% de los pacientes no consumió píldoras, el 18% consumió todo y el 5% requirió equianalgesica adicional. Del total de píldoras recetadas, el 63% no se consumió. El consumo fue significativamente diferente según la categoría de la operación (promedio de 13,6 píldoras de oxicodona equianalgésica de 5 mg después de las hemorroidectomías, 6,3 después de las operaciones de fístula en el ano, 5,8 después de la fulguración del condiloma y 2,9 después de las operaciones misceláneas, p <0,001). Los requisitos de opioides en el hogar se cumplirían para el 80% de los pacientes con las siguientes pautas: 27 píldoras de oxicodona equianalgésicas de 5 mg después de las hemorroidectomías, 13 después de las operaciones de fístula anal, 20 después de la fulguración del condiloma anal y 4 después de operaciones misceláneas. La adopción de la guía daría como resultado una reducción del 41% en el exceso de píldoras por receta.El estudio estuvo limitado por su diseño retrospectivo de un solo centro y el consumo de opioides fue autoinformado.Los patrones de prescripción de opioides y el consumo son variables después de las operaciones anorrectales y parecen ser altamente dependientes de la categoría de la operación. En particular, el 63% de los opioides recetados después de las operaciones anorrectales no fueron utilizados por el paciente y pueden representar un riesgo significativo para la salud pública. Según los patrones de uso observados en este estudio, se deben realizar estudios prospectivos para optimizar la prescripción de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B374.

Creation and Institutional Validation of a Readmission Risk Calculator for Elective Colorectal Surgery.

BACKGROUND: Readmissions reflect adverse patient outcomes, and clinicians currently lack accurate models to predict readmission risk. OBJECTIVE: We sought to create a readmission risk calculator for use in the postoperative setting after elective colon and rectal surgery. DESIGN: 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. SETTINGS: The study included both national and institutional data. PATIENTS: Patients who underwent elective abdominal colon or rectal resection were included. MAIN OUTCOME MEASURES: The primary outcome was readmission within 30 days of surgery. Secondary outcomes included reasons for and time interval to readmission. RESULTS: The model discrimination (c-statistic) was 0.76 ((95% CI, 0.75-0.76); p < 0.0001) in the National Surgical Quality Improvement Program model creation cohort (n = 50,508), 0.70 ((95% CI, 0.69-0.70); p < 0.0001) 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. LIMITATIONS: This was a retrospective observational review. CONCLUSIONS: 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, p < 0,0001) en la cohorte de creación del modelo NSQIP (n = 50,508), 0,70 (IC del 95%: 0,69-0,70, p < 0,0001) 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 como > 8,7% 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).

Data Accuracy and Predictors of High Ratings of Colon and Rectal Surgeons on an Online Physician Rating Website.

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 < 0.001), 5-star rating was associated with 1 to 9 years (OR = 2.76; p = 0.04) or >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. PRECISIÓN DE DATOS Y PREDICTORES DE ALTAS CALIFICACIONES DE CIRUJANOS DE COLON Y RECTO EN UN SITIO WEB DE CALIFICACIÓN MÉDICA EN LÍNEA: Más de la mitad de los consumidores utilizan los sitios web de calificación de médicos en línea para seleccionar médicos. Ningún estudio ha examinado los sitios web de calificación de médicos para cirujanos de colon y recto.Evaluar la precisión y los patrones de calificación de los cirujanos de colon y recto en el sitio web más grande de calificación de médicos.Las características y calificaciones de los médicos se obtuvieron de una muestra seleccionada al azar de 500 de 3,043 "especialistas en cirugía de colon y recto" de Healthgrades. Las certificaciones del Consejo se verificaron en los sitios web del Consejo Americano de Cirugía y del Consejo Americano de Cirugía de Colon y Recto.La adquisición de datos se completó el 18 de julio de 2018.Los pacientes no fueron estudiados directamente.El resultado primario fue evaluar la precisión de Healthgrades al informar la certificación por el Consejo Americano de Cirugía y por el Consejo Americano de Cirugía 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 análisis subsecuente. Healthgrades mostró un 80.1% de concordancia con las certificaciones verificadas del Consejo Americano de Cirugía y el 85.4% con el Consejo Americano de Cirugía de Colon y Recto. La calificación promedio de estrellas fue 4.2 / 5 (SD 0.9), y 77 (21.6%) tuvieron calificaciones de 5 estrellas. En un modelo logístico multivariable (p <0.001), la calificación de 5 estrellas se asoció con 1-9 años (OR 2.76, p = 0.04) o más de 40 años en la práctica (OR 3.35, p = 0.04) y menos evaluaciones (OR 0.88, p <0.001). No hubo asociaciones significativas con el género, edad, región geográfica o certificación por los Consejos del cirujano.Los datos se limitaron a un solo sitio web de calificación de médicos.En la era moderna del consumismo en atención médica, los sitios web de calificación de los médicos deben usarse con precaución debido a imprecisiones. Se necesitan recursos en línea más precisos para que las decisiones de los pacientes sean informadas en la selección de atención quirúrgica especializada de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B91. (Traducción-Dr. Jorge Silva-Velazco).

The utility of the delphi method in defining anastomotic leak following colorectal surgery.

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.

Impact of Preoperative Care for Rectal Adenocarcinoma on Pathologic Specimen Quality and Postoperative Morbidity: A NSQIP Analysis.

BACKGROUND: 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. STUDY DESIGN: 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. RESULTS: 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, p < 0.001), 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. CONCLUSIONS: 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.

The Pregnant Surgeon.

The proportion of women entering medicine and surgery is increasing steadily. As more women surgeons have children during residency and practice, it is essential that we adopt a team approach to the pregnant surgeon, as a pregnancy undoubtedly impacts the team and not just the individual. Coauthored by a practicing surgeon mother of 2 (J. D.) and a postgraduate year 8 colorectal surgery fellow mother of 2 who is currently pregnant (C. H.), we aim to review the data while providing some practical advice for pregnant surgeons and those considering pregnancy, as well as their valued colleagues, mentors, and administrators. Physical challenges are discussed by trimester, as are the risks facing the pregnant surgeon, the logistics of transitioning in and out of maternity leave, and postpartum considerations.

Postoperative Ileus.

Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.

Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample.

BACKGROUND: The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume. METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology. RESULTS: A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups. CONCLUSION: No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation.

BACKGROUND: Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage. MATERIALS AND METHODS: We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality. RESULTS: From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05). CONCLUSION: Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Patients with psychiatric comorbidity can safely undergo bariatric surgery with equivalent success.

INTRODUCTION: Patients with psychiatric disorder were reported to have a poor outcome in bariatric surgery. Few studies have examined the outcome of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in patients with psychiatric history. We aimed to compare excess weight loss (%EWL) in patients with and without psychiatric comorbidities who underwent LSG or LAGB. METHODS: Patients undergoing LSG or LAGB were identified from our prospective database. A multidisciplinary team evaluated all patients preoperatively, including a psychological evaluation. Patients with the diagnosis of depression, anxiety, bipolar disorder, and schizophrenia were included in the psychiatric comorbidity group (PSY). Others were included in group NON-PSY. All patients were first screened to be psychologically stable to undergo surgery. Initial BMI and %EWL at 3, 6, and 12 months postoperatively were compared. RESULTS: A total of 590 patients (81.4 % women), with a median BMI of 43.8 kg/m(2) (range 30-99) who underwent LSG (n = 222) or LAGB (n = 368) from January 2006 to June 2013, were identified. Psychiatric comorbidities that were well controlled at the time of surgery were found in 188 patients (31.9%). Diagnostic criteria for depression were met in 154 patients (26.1%), 75 patients suffered from anxiety (12.7%), 9 from bipolar disorder, and 4 from schizophrenia (0.7%). Initial BMI was not different between the two groups. No significant difference in %EWL between the groups was found during follow-up (44.13 vs. 43.37%EWL, respectively, at 1 year; p = 0.76). When LSG and LAGB patients were analyzed as subsets, again no difference in %EWL at 1 year was found for PSY vs. NON-PSY (LSG: 51.56 vs. 54.86%EWL; LAGB: 38.48 vs. 38.45%EWL, all p = ns). In multivariate analysis, the differences from unadjusted analysis persisted. CONCLUSION: These findings demonstrate that a similar %EWL can be achieved in patients undergoing LSG or LAGB despite the presence of well-controlled psychiatric comorbidity.

Phase II clinical experience and long-term follow-up using the next-generation single-incision platform FMX314.

BACKGROUND: Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar we previously described in six patients with short-term follow-up data. The objective of this phase II study was to evaluate the safety and feasibility of the platform in a larger collective and to evaluate 1-year follow-up data of the phase I trial. METHODS: The technology features a multiple-use introducer, accommodating the articulating instruments, and is inserted through a 15-mm laparoscopic trocar. Cholecystectomy is performed through an umbilical incision. A prospective feasibility study was performed at a single center. Inclusion criteria were age of 18-75 years and biliary colic, exclusion criteria were acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included complications, length of stay, pain medication, cosmetic results, and the presence of hernia. RESULTS: Twenty-seven patients (23 females; phase I: 6 patients, phase II: 21 patients) with an average age of 41.7 years and BMI 26.6 kg/m(2) were recruited for the study. Umbilical incision length did not exceed 15 mm. There were no intraoperative complications. Average OR time decreased from 91 min for the first six cases to 56 min for the last six cases. Average length of stay was 7.8 h. Pain control was achieved with diclofenac for no more than 7 days. All patients had no adverse events at 5-month follow-up, and all phase I patients had no adverse events nor evidence of umbilical hernia at 1 year. CONCLUSION: This study demonstrates that single-incision cholecystectomy with the platform is feasible, safe, and reproducible in a larger patient population. Long-term follow-up showed no hernias or other adverse events. Further studies will be needed to evaluate longer-term hernia rates.

Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery.

BACKGROUND: Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. RESULTS: From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy. CONCLUSION: In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings.

Benefits of bariatric surgery do not reach obese men.

BACKGROUND: Epidemiological studies have shown an equal gender distribution of obesity in the United States; however, literature suggests approximately 80% of patients undergoing bariatric surgery are female. The aim of this study is to identify factors that contribute to this gender disparity. STUDY DESIGN: A retrospective analysis of the Nationwide Inpatient Sample was performed. Obese patients who underwent open or laparoscopic gastric bypass or sleeve gastrectomy were identified using International Classification of Diseases, 9th edition codes. Patients <18 years of age were excluded. Female gender was used as a dependent variable to determine factors that influence gender distribution. Multivariate analyses adjusted for age, race, state within the United States, Charlson Comorbidity Index, income level, and insurance status. RESULTS: From 1998 to 2010, 190,705 patients underwent bariatric surgery (93% gastric bypass, 7% sleeve gastrectomy). Females made up 81.36% of the population. An 80% to 20% female to male distribution was maintained for every year (1998-2010) and was unchanged within individual states. Patients were more likely to be female if from a lower-income neighborhood or if African American or Hispanic (P<.05). Patients were less likely to be female with increasing age, more comorbidities, or private insurance (P<.05). CONCLUSIONS: The unequal gender distribution in bariatric surgery patients is influenced by demographic and socioeconomic factors. This disparity is narrowed in patients who are older and have more comorbidities, whereas the disparity is widened for certain races and lower incomes. Given the equal distribution of obesity in the United States, the widespread gender gap in bariatric surgery may suggest an underuse in obese men.

Laparoscopic cholecystectomy using a novel single-incision surgical platform through a standard 15 mm trocar: initial experience and technical details.

OBJECTIVE: Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar. The objective of this study is to evaluate the safety and feasibility of the platform. METHODS: The technology is currently a Phase I investigational device. It features articulating surgical instruments and is inserted through a multiple-use introducer. The platform's introducer requires a standard 15-mm laparoscopic trocar. Cholecystectomy is performed through a 15-mm umbilical incision utilizing an additional epigastric 2-mm needle-port grasper for gallbladder retraction. A prospective feasibility study was performed at a single-center. Inclusion criteria were age 18-75 years and biliary colic. Patients were excluded if they had acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included the success rate of the platform, hospital length of stay, post-operative pain medication usage, cosmetic results, and presence of hernia. RESULTS: Six patients (5 female) with an average age of 41 years and BMI 28 kg/m(2) underwent cholecystectomy with the platform. Average OR time was 91 min and umbilical incision length did not exceed 15 mm. One case was converted to standard laparoscopy due to mechanical failure of the clip applier instrument. There were no intraoperative complications. Post-operatively, two patients developed self-resolving umbilical ecchymoses. Average length of stay was 13 h. Pain control was achieved with diclofenac for less than 7 days. At 1 month follow-up there were no complications and no umbilical hernias. CONCLUSIONS: This phase I study demonstrates that single-incision cholecystectomy through a 15-mm trocar with the Fortimedix Surgical B.V. single-incision surgical platform is feasible, safe, and reproducible. Additional benefits include excellent triangulation and range of motion as well as exceptional cosmetic results. Further studies will be needed to evaluate long-term hernia rates.

Magnetic lower esophageal sphincter augmentation device removal.

Implantation of a magnetic lower esophageal sphincter augmentation device is now an alternative to fundoplication in the surgical management of gastroesophageal reflux disease (GERD). Although successful management of GERD has been reported following placement of the device, there are instances when device removal is needed. The details of the technique for laparoscopic magnetic lower esophageal sphincter device removal are presented to assist surgeons should device removal become necessary.

Laparo-endoscopic transgastric resection of gastric submucosal tumors.

BACKGROUND: Laparoscopic and endoluminal surgical techniques have evolved and allowed improvements in the methods for treating benign and malignant gastrointestinal diseases. To date, only case reports have been reported on the application of a laparo-endoscopic approach for resecting gastric submucosal tumors (SMT). In this study, we aimed to evaluate the efficacy, safety, and oncologic outcomes of a laparo-endoscopic transgastric approach to resect tumors that would traditionally require either a laparoscopic or open surgical approach. Herein, we present the largest single institution series utilizing this technique for the resection of gastric SMT in North America. METHODS: We performed a retrospective review of a prospectively collected patient database. Patients who presented for evaluation of gastric SMT were offered this surgical procedure and informed consents were obtained for participation in the study. RESULTS: Fourteen patients were included in this study between August/2010 and January/2013. Eight (8) patients (57.1 %) were female and the median age was 56 years (range 29-78). Of the 14 cases, 8 patients (57.1 %) underwent laparo-endoscopic resection of SMTs with transgastric extraction, 5 patients (35.7 %) had conversions to traditional laparoscopic surgery, and 1 patient (7.2 %) was abandoned intraoperatively. The median operative time for this cohort was 80 min (range 35-167). Ten patients (71.4 %) had GISTs, 3 (21.4 %) had leiomyomas, and 1 (7.1 %) had schwannoma. There were no intraoperative complications. Two patients had postoperative staple line bleeding that required repeat endoscopy. The median hospital stay was 1 day (range 1-6) and there were no postoperative mortalities. At 12-month follow-up visit, only one GIST patient (10 %) had tumor recurrence. CONCLUSION: Our experience suggests that this surgical approach is safe and efficient in the resection of gastric SMT with transgastric extraction. This study found no intraoperative complications and optimal oncologic outcomes during the follow-up period. Minimally invasive surgical approaches are emerging as a valid and potentially better approach for resecting malignancies; however, continued investigation is underway to further validate this data.

Foramen of Winslow hernia: a minimally invasive approach.

Hernias through the foramen of Winslow comprise 8 % of all internal hernias and the majority contain incarcerated bowel. Clinical signs are often non-specific and delay in diagnosis associated with a mortality rate that approaches 50 %. Management is urgent surgical reduction with bowel decompression and resection of devitalized bowel. A foramen of Winslow hernia (FWH) has traditionally been managed via an exploratory laparotomy incision and the vast majority of cases describe an open approach. We describe a minimally invasive approach to the management of an incarcerated FWH requiring decompression and bowel resection.