Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade.

BACKGROUND: The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution. METHODS: We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events. RESULTS: In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022. CONCLUSIONS: Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

Reoperations after sleeve gastrectomy: a dual academic institutional experience.

BACKGROUND: Although laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed worldwide, patients can experience complications and poor outcomes that warrant reoperations. The incidence, indications, and outcomes of reoperations are not well understood. OBJECTIVE: To describe indications and outcomes for reoperations after LSG. SETTING: Two academic, tertiary care hospitals. METHODS: We performed a retrospective observational cohort review of institutional Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2014-2018 and reviewed charts of all reoperations after LSG. We analyzed demographics, preoperative symptoms and work-up, and postoperative outcomes. RESULTS: Fifty-seven reoperations after LSG represented 3.0% of 1965 bariatric cases performed. Most LSGs (56.1%) were performed outside our academic centers. Median time to reoperation and follow-up were 2.63 and 1.2 years, respectively. Conversion to gastric bypass was the most common reoperation (77.2%). More than half of the patients (52.6%) had multiple indications for reoperation. Reflux was the most common primary indication for reoperation (47.3%), followed by incisural strictures (20.1%), inadequate weight loss (17.5%), and leak/fistulae (12.2%). Reoperations were most successful when performed for reflux (92.5%) and oral intolerance from strictures (92%), whereas only 71.4% of leak/fistulas resolved. Surgery for inadequate weight loss resulted in total weight loss of 24.7 ± 10.1%. Complications occurred in 36.2% of cases but varied by indication. CONCLUSION: Symptoms and complications after LSG can persist, and patients may require reoperation. Reoperations can successfully treat the primary indications for reoperation and should be offered, but they have higher complication rates than initial operations.

The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience.

BACKGROUND: Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success. METHODS: A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes. RESULTS: Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program. CONCLUSION: I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

Region and Insurance Plan Type Influence Discharge Disposition After Hip and Knee Arthroplasty: Evidence From the Privately Insured US Population.

BACKGROUND: Little is known about regional variation in the use of postacute care services after elective procedures, such as total hip or knee arthroplasty (THA/TKA), and how insurance type may influence it. The goal of this study is to assess the influence of region and insurance arrangements on discharge disposition. METHODS: A representative sample of the privately insured US population with THA or TKA in 2009 or 2010 was obtained from the MarketScan database applying individual-level weights from the Medical Expenditure Panel Survey. Multivariate logistic regression was used to predict the odds of being discharged to an extended care facility (ECF) compared with being discharged home. The model adjusted for region, insurance plan type, sociodemographic characteristics, comorbidities, and length of stay. RESULTS: Large variability was observed in ECF use across the US. Patients in the Northeast were 2.5 times more likely to receive care at an ECF compared with patients in the South (odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.97-3.19). Enrollees in noncapitated plans such as fee-for-service plans or exclusive provider organizations were less likely to be discharged to an ECF compared with health maintenance organizations/preferred provider organizations with capitation enrollees (OR = 0.74, 95% CI: 0.57-0.94; OR = 0.49, 95% CI: 0.34-0.74, respectively). CONCLUSION: Region and private insurance plan arrangements are related to extended care use among THA and TKA patients. Understanding regional variation in discharge disposition provides policy makers with important information as to where to focus new tests of hip and knee procedures such as same day arthroplasty.

Socially Responsible Surgery: Building Recognition and Coalition.

IMPORTANCE: Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals. OBJECTIVE: We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries. EVIDENCE REVIEW: We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions. CONCLUSION: There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Evaluating organizational factors associated with postoperative bariatric surgery readmissions.

BACKGROUND: Several patient and surgical characteristics have been identified as risk factors for readmission after bariatric surgery, but there is a paucity of information on how organizational factors influence this metric. OBJECTIVE: To evaluate the association between readmissions and several organizational factors, including compliance with best practices to reduce unplanned hospital visits, major complication rates, and the emergency department-sourced readmission (EDSR) rate. METHODS: The Michigan Bariatric Surgery Collaborative database was used to identify patients undergoing primary bariatric procedures. Using an indirect standardization process, each site's observed-to-expected ratio for 30-day readmissions was calculated. The association between each site's adjusted readmission rate and each organizational factor was calculated with Pearson correlation coefficients. RESULTS: There was significant variation among the sites' adjusted rates of readmission, EDSR, best practice compliance rates, and major complication rates. There was a moderate association between each site's adjusted readmission rate and the rate of EDSR (r = .53) and major complications (r = .53). However, the association between bariatric centers' compliance with best practices to reduce unplanned hospital visits and readmission rates was fairly weak (r = -.14). CONCLUSION: Bariatric centers with higher rates of major complications and sites with emergency departments that are less likely to treat and discharge patients are more likely to have higher readmission rates. Even though compliance with best practices to reduce readmissions may be important, results suggest that it does not significantly influence the readmission rates at sites that perform only these basic measures or perform them inadequately.

Evaluation of a Standardized Risk-Based Venous Thromboembolism Prophylaxis Protocol in the Setting of Thyroid and Parathyroid Surgery.

BACKGROUND: An elevated odds ratio for venous thromboembolism (VTE) prompted development of a Caprini risk assessment and risk-based prophylaxis protocol for all general surgery patients. This system includes pre- and postoperative prophylactic heparin as well as extended courses of low molecular weight heparin for high-risk patients. This study evaluated the safety of this chemoprophylaxis program in thyroid and parathyroid surgery. STUDY DESIGN: A retrospective review was conducted of all general surgery patients undergoing thyroid or parathyroid operations after implementation of the Caprini prophylaxis protocol. Descriptive statistics were performed to evaluate bleeding complications, risk score categories, and chemoprophylaxis. RESULTS: Of 1,012 consecutive patients, 72% were determined to be at low/moderate risk for VTE, 26% were high risk, and 2% were highest risk. Only 29% of eligible high/highest-risk patients actually received extended prophylaxis after discharge. Fifteen patients (1.5%) developed wound hematomas that required evacuations, 12 of them within 24 hours of the index operation. Among patients who developed bleeding complications, 5 (33%) had Caprini scores indicating low/moderate-risk for VTE, and 10 (67%) were in the high/highest-risk categories. Only 1 patient developed a delayed hematoma that required a return to the hospital for evacuation. One patient developed a VTE complication. CONCLUSIONS: Although the incidence of VTE is quite low for patients undergoing thyroid and parathyroid operations, the Caprini prophylaxis protocol identifies a subset of high-risk patients who may benefit from extended VTE prophylaxis without the likelihood of added harm. Conversely, Caprini scores might also select low-risk patients who require no chemoprophylaxis, possibly reducing risks of hemorrhage.

Factors associated with bariatric postoperative emergency department visits.

BACKGROUND: Unplanned bariatric postoperative emergency department (ED) visits occur frequently and may represent inadequate coordination of postdischarge care. Multicenter data on this outcome is limited, as this metric has not traditionally been tracked in large clinical databases. OBJECTIVES: To describe the frequency of and risk factors associated with 90-day postoperative ED visits after bariatric surgery. SETTING: Truven Health Analytics MarketScan database. METHODS: All patients undergoing primary bariatric operations in the 2012 and 2013 MarketScan database were included. The primary outcome was the presence of an ED visit not resulting in a hospital readmission within 90 days of surgical discharge. Risk factors and demographic characteristics evaluated included age, sex, co-morbidities, insurance type, region, operation type, prior ED visits within 1 year, and index admission length of stay. RESULTS: Postoperative ED visits not associated with an inpatient admission occurred in 14.6% of patients. The most common diagnoses associated with these visits were abdominal pain (24.4%) and dehydration, nausea, or vomiting (20.8%). On multivariate analysis, younger age, female sex, greater number of co-morbidities, north-central region, open bariatric or laparoscopic gastric bypass operations,≥2 prior ED visits, and increased initial length of stay were all associated with increased odds of an ED visit. CONCLUSIONS: Postoperative ED visits are a frequent and potentially preventable occurrence with several risk factors. Tracking this metric as a quality indicator will allow for targeted interventions to improve the transition of care to the outpatient setting after bariatric surgery.

An Exploration of System-Level Factors and the Geographic Variation in Bariatric Surgery Utilization.

There is wide geographic variation in bariatric surgery rates, although higher regional rates of obesity are not correlated with higher rates of surgery. In this study, four system-level factors were explored as contributors to this geographic variation. Geographic utilization rates of bariatric surgery showed no correlation to the number of bariatric surgeons, number of accredited centers, and the percentage of patients with a recent primary care visit. The total number of surgical discharges was weakly correlated with bariatric surgery rates (r = 0.26, p = <0.001). As surgeon supply, accredited bariatric centers, overall surgical volume, and access to primary care do not appear to heavily influence bariatric surgery rates, future studies are needed to identify additional factors that may explain the underutilization of bariatric surgery.

Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol.

BACKGROUND: Venous thromboembolism (VTE) is a leading contributor to morbidity after operations. We previously implemented a standardized VTE risk assessment, based on the Caprini score, along with risk-stratified prophylaxis. This system reduced the odds ratio of a VTE event from 3.02 to 0.75. We investigated patterns of failure to determine characteristics of patients in whom VTE develops despite the protocol. METHODS: We reviewed all nontrauma general surgery patients with evidence of VTE after the inception of a VTE risk assessment and prophylaxis program. Characteristics were recorded, including demographics, diagnoses, operations, risk profile, prophylaxis prescribed, and regimen compliance. RESULTS: Twenty-seven patients failed the protocol and manifested VTE, representing an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations, compared with 13% and 2.0% of the nontrauma general surgery population in whom VTE did not develop, respectively (p < 0.001). Of patients with VTE, 52% had pre-existing or postoperative infections, 22% had malignancies, but only 15% had missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five VTEs manifested after discharge; one of those patients was prescribed extended prophylaxis beyond hospitalization, and an extended course was not provided to 3 who were eligible. One patient had underestimation of the Caprini score due to lack of awareness of a family history of VTE. CONCLUSIONS: Emergency and multiple operations seem to confer dramatic hazards for VTE, despite standard prophylaxis. These factors are not currently captured in the Caprini model, but might be significant modifiers of risk that should prompt reassessment, perhaps with a weighted numeric value along with enhanced prophylaxis. It is encouraging that most patients received appropriate prophylaxis in compliance with the protocol.

A Multifaceted Intervention to Increase Surgery Resident Engagement in Reporting Adverse Events.

BACKGROUND: Although most residents have been involved in an adverse or near-miss event, they are not likely to report these incidents. To improve the culture of patient safety and to increase adverse event reporting among General Surgery residents, a multifaceted intervention focused on education, feedback, and event resolution was developed and implemented. METHODS: Adverse events involving surgery patients at Boston Medical Center were monitored for 2 months before and for 10 months after implementation of the intervention in May 2014. RESULTS: There was a significant increase in the number of adverse events reported by residents, from 0 to 30 per 2-month period (χ(2) = 8.56, p = 0.003). The classification types of reports filed by residents differed significantly from those of incidents submitted by other reporters (p < 0.0001). CONCLUSION: An intervention focused on addressing barriers to reporting adverse events can significantly increase the volume of incidents reported by surgery residents. Involving residents in patient safety efforts may enhance an institution's ability to identify adverse events and to improve the overall culture of care.

Giant Colonic Diverticulum: a Rare Diagnostic and Therapeutic Challenge of Diverticular Disease.

A giant colonic diverticulum is a diverticulum of the colon greater than 4 cm in diameter that can present, albeit rarely, as a complication of diverticular disease. We discuss the three different histologic subtypes that have been described and the challenges in the diagnosis and treatment.

Distal airway dysfunction in obese subjects corrects after bariatric surgery.

BACKGROUND: Obesity is frequently associated with respiratory symptoms despite normal large airway function as assessed by spirometry. However, reduced functional residual capacity and expiratory reserve volume are common and might reflect distal airway dysfunction. Impulse oscillometry (IOS) might identify distal airway abnormalities not detected using routine spirometry screening. Our objective was to test the hypothesis that excess body weight will result in distal airway dysfunction detected by IOS that reverses after bariatric surgery. The setting was a university hospital. METHODS: A total of 342 subjects underwent spirometry, plethysmography, and IOS before bariatric surgery. Of these patients, 75 repeated the testing after the loss of 20% of the total body weight. The data from 47 subjects with normal baseline spirometry and complete pre- and postoperative data were analyzed. RESULTS: IOS detected preoperative distal airway dysfunction despite normal spirometry findings by an abnormal airway resistance at an oscillation frequency of 20 Hz (4.75 ± 1.2 cm H2O/L/s), frequency dependence of resistance from 5 to 20 Hz (2.20 ± 1.6 cm H2O/L/s), and reactance at 5 Hz (-3.47 ± 2.1 cm H2O/L/s). Postoperatively, the subjects demonstrated 57% ± 15% excess weight loss. The body mass index decreased (from 44 ± 6 to 32 ± 5 kg/m2, P < .001). Improvements in functional residual capacity (from 59% ± 11% to 75% ± 20% predicted, P < .001) and expiratory reserve volume (from 41% ± 20% to 75% ± 20% predicted, P < .001) were demonstrated. Distal airway function also improved: airway resistance at an oscillation frequency of 20 Hz (3.91 ± .9, P < .001), frequency dependence of resistance from 5 to 20 Hz (1.17 ± .9, P < .001), and reactance at 5 Hz (-1.85 ± .9, P < .001). CONCLUSION: The present study detected significant distal airway dysfunction despite normal preoperative spirometry findings. The effect of increased body weight was likely the main mechanism for these abnormalities. However, the inflammatory state of obesity or associated respiratory disease could also be invoked. These abnormalities improved significantly toward normal after weight loss. The results of the present study highlight the importance of bariatric surgery as an effective intervention in reversing these respiratory abnormalities.