Creating a learning healthcare system in surgery: Washington State's Surgical Care and Outcomes Assessment Program (SCOAP) at 5 years.

There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.

Emergent treatment of a primary aortoenteric fistula with N-butyl 2-cyanoacrylate and endovascular stent.

A novel endovascular treatment involving cyanoacrylate injection followed by endovascular stent placement is described in the setting of life-threatening acute exsanguination through a primary aortoenteric fistula. In a patient in unstable condition, N-butyl 2-cyanoacrylate was injected into the fistula tract. Rapid polymerization first provided hemostasis and allowed the patient to be resuscitated and stabilized for several hours, and then an AneuRx endovascular stent-graft was deployed to reinforce the aortic wall and permanently occlude the fistula. This approach can benefit patients whose condition would otherwise be too unstable for open surgery.