Initiating statistical process control to improve quality outcomes in colorectal surgery.

BACKGROUND: Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery. METHODS: Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group. RESULTS: A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates. CONCLUSIONS: SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway.

BACKGROUND: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use. OBJECTIVE: The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes. DESIGN: This was a case-matched study. METHODS: After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex. SETTINGS: This study was performed at a tertiary referral center. PATIENTS: Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included. MAIN OUTCOME MEASURES: The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway. RESULTS: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen. LIMITATIONS: The single-surgeon, single-institution design was a limitation of this study. CONCLUSIONS: The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

Prone jackknife position is not necessary to achieve a cylindrical abdominoperineal resection: demonstration of the lithotomy position.

This video demonstrates a laparoscopic abdominal perineal resection for a fixed 4.8-cm mass involving the posterior and left rectal walls and left puborectalis, 2 cm from the anal verge (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A127). We detail the steps of the procedure, all completed in lithotomy, including lateral-to-medial dissection; identification and protection of the left ureter and presacral nerves; division of the inferior mesenteric artery; medial-to-lateral dissection, with meeting the previous dissection plane; total mesorectal excision and pelvic dissection; perineal dissection and layered closure; and abdominal inspection and colostomy creation. Total operative time was 181 minutes. The specimen total mesorectal excision was complete with a negative circumferential radial margin (greater than 1 cm). Final pathology was T3N2M0.

Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection.

BACKGROUND: During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery. METHODS: A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups. RESULTS: A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery. CONCLUSIONS: RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.

Optimizing cost and short-term outcomes for elderly patients in laparoscopic colonic surgery.

BACKGROUND: Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy. Our hypothesis was that elderly patients managed with laparoscopic colorectal surgery and an enhanced recovery protocol (ERP) can realize the same benefits of lower hospital length of stay (LOS) without increasing hospital costs or readmission rates. METHODS: Review of a prospective database identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012. Patients were stratified into elderly (≥70 years old) and nonelderly (<70 years old) cohorts. The main outcome measures were discharge disposition, hospital costs, hospital LOS, and 30-day readmission rates between the laparoscopic and open groups. RESULTS: A total of 302 nonelderly (66%) and 153 elderly (34%) patients were included in the analysis. The elderly cohort had significantly higher comorbidities than the nonelderly group. There were no mortalities. Operative variables (procedure time, blood loss, and intraoperative complications) were similar. At discharge, significantly more elderly patients required temporary nursing or home care. There were no significant differences in short-term outcomes of LOS, 30-day readmission rates, or costs for the episode of care between the two groups. CONCLUSIONS: Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients. Despite higher comorbidities, elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates.

Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways.

BACKGROUND: Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates. STUDY DESIGN: A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group. RESULTS: Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively. CONCLUSIONS: Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality.

Familial paraganglioma: a novel presentation of a case and response to therapy with radiolabelled MIBG.

Phaeochromocytomas (PC) and paragangliomas are disorders of the sympatho-adrenomedullary system. They are chromaffin-containing neuroendocrine tumors of neural crest origin that contain catecholamine-secreting granules: they arise from either the adrenal medulla (phaeochromocytomas) or from extra-adrenal neural crest derivatives e.g. the sympathetic chain (paragangliomas). The term paraganglioma is also used for vascular head and neck tumors derived from parasympathetic tissue, which commonly arise at the carotid bifurcation. It has been reported that some 10% of phaeochromocytomas are part of a familial syndrome, although recent data have suggested that germline mutations in known predisposing syndromes, such as multiple endocrine neoplasia type 2 (MEN2) and Von Hippel-Lindau (VHL), occur in a much higher percentage. However, familial genetic syndromes have been said to be less common in paragangliomas, although more recently described genetic syndromes may not have been considered. Thus, there is increasing evidence that mutations of subunits of the succinate dehydrogenase gene (SDHB, SDHC & SDHD) may confer susceptibility to paragangliomas and head-and-neck paragangliomas (HNPGL). We report a case of a patient with a previously published gene mutation in SDHB who had a single paraganglioma arising from the bladder with a characteristic clinical presentation, and in whom there was a positive family history of a HNPGL. He has demonstrated malignant recurrence with metastases which have been treated, so far successfully, with radiolabelled MIBG.