Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery.

BACKGROUND: Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. METHODS: We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. RESULTS: Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. CONCLUSION: Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

Premature T Cell Senescence in Pediatric CKD.

An individual's immune function, susceptibility to infection, and response to immunosuppressive therapy are influenced in part by his/her T cell maturation state. Although childhood is the most dynamic period of immune maturation, scant information regarding the variability of T cell maturation in children with renal disease is available. In this study, we compared the T cell phenotype in children with renal failure (n=80) with that in healthy children (n=20) using multiparameter flow cytometry to detect markers of T cell maturation, exhaustion, and senescence known to influence immune function. We correlated data with the degree of renal failure (dialysis or nondialysis), prior immunosuppression use, and markers of inflammation (C-reactive protein and inflammatory cytokines) to assess the influence of these factors on T cell phenotype. Children with renal disease had highly variable and often markedly skewed maturation phenotypes, including CD4/CD8 ratio reversal, increased terminal effector differentiation in CD8+ T cells, reduction in the proportion of naïve T cells, evidence of T cell exhaustion and senescence, and variable loss of T cell CD28 expression. These findings were most significant in patients who had experienced major immune insults, particularly prior immunosuppressive drug exposure. In conclusion, children with renal disease have exceptional heterogeneity in the T cell repertoire. Cognizance of this heterogeneity might inform risk stratification with regard to the balance between infectious risk and response to immunosuppressive therapy, such as that required for autoimmune disease and transplantation.

Utility of Prostate Cancer Screening in Kidney Transplant Candidates.

Screening recommendations for prostate cancer remain controversial, and no specific guidelines exist for screening in renal transplant candidates. To examine whether the use of prostate-specific antigen (PSA)-based screening in patients with ESRD affects time to transplantation and transplant outcomes, we retrospectively analyzed 3782 male patients ≥18 years of age undergoing primary renal transplant evaluation during a 10-year period. Patients were grouped by age per American Urological Association screening guidelines: group 1, patients <55 years; group 2, patients 55-69 years; and group 3, patients >69 years. A positive screening test result was defined as a PSA level >4 ng/ml. We used univariate analysis and Cox proportional hazards models to identify the independent effect of screening on transplant waiting times, patient survival, and graft survival. Screening was performed in 63.6% of candidates, and 1198 candidates (31.7%) received kidney transplants. PSA screening was not associated with improved patient survival after transplantation (P=0.24). However, it did increase the time to listing and transplantation for candidates in groups 1 and 2 who had a positive screening result (P<0.05). Furthermore, compared with candidates who were not screened, PSA-screened candidates had a reduced likelihood of receiving a transplant regardless of the screening outcome (P<0.001). These data strongly suggest that PSA screening for prostate cancer may be more harmful than protective in renal transplant candidates because it does not appear to confer a survival benefit to these candidates and may delay listing and decrease transplantation rates.

The Association Between Hospital Finances and Complications After Complex Abdominal Surgery: Deficiencies in the Current Health Care Reimbursement System and Implications for the Future.

OBJECTIVE: To determine the relationship between complications after 3 common general surgery procedures and per-episode hospital finances. BACKGROUND: With impending changes in health care reimbursement, maximizing the value of care delivered is paramount. Data on the relative clinical and financial impact of postoperative complications are necessary for directing surgical quality improvement efforts. METHODS: We reviewed the medical records of patients enrolled in the American College of Surgeons' National Surgical Quality Improvement Program who underwent pancreaticoduodenectomy, hepatectomy, and colectomy at a single academic institution between September 2009 and August 2012. Clinical outcomes data were subsequently linked with hospital billing data to determine hospital finances associated with each episode. We describe the association between postoperative complications, hospital length of stay, and different financial metrics. Multivariable linear regression modeling tested linear association between postoperative outcomes and cost data. RESULTS: There was a positive association between the number of surgical complications, payments, length of stay, total charges, total costs, and contribution margin for the three procedures. Multivariable models indicated that complications were independently associated with total cost among the selected procedures. Payments increased with complications, offsetting increased costs. CONCLUSIONS: In the current fee-for-service environment, the financial incentives are misaligned with quality improvement efforts. As we move to a value-driven method of reimbursement, administrators and health care providers alike will need to focus on improving the quality of patient care while remaining conscious of the cost of care delivered. Reducing complications effectively improves value.

Renal safety of intravenous gadolinium-enhanced magnetic resonance imaging in patients awaiting liver transplantation.

Renal dysfunction in cirrhosis carries a high morbidity and mortality. Given the potential risk of contrast-induced nephropathy associated with iodinated intravenous contrast used in computed tomography (CT), alternate contrast modalities for abdominal imaging in liver transplant candidates need to be examined. The purpose of this study was to examine the renal safety of magnetic resonance imaging (MRI) with gadolinium in patients awaiting liver transplantation. The study involved a retrospective analysis of 352 patients of abdominal MRI with low-dose gadobenate dimeglumine (MultiHance) (0.05 mmol/kg) in patients with cirrhosis and without renal replacement therapy at a single center during the period from 2007 to 2013. For each case, serum creatinine before and within a few days after the MRI were compared. In addition, the patients were analyzed for the development of nephrogenic systemic fibrosis (NSF), a reported complication of gadolinium in chronic kidney disease. The pre-MRI serum creatinine values ranged from 0.36 to 4.86 mg/dL, with 70 patients (20%) having values ≥ 1.5 mg/dL. A comparison of the pre- and post-MRI serum creatinine values did not demonstrate a clinically significant difference (mean change = 0.017 mg/dL; P = 0.38), including those patients with a pre-MRI serum creatinine ≥ 1.5 mg/dL. In addition, no cases of NSF were noted. In conclusion, our findings suggest that MRI with low-dose gadobenate dimeglumine (MultiHance) is a nonnephrotoxic imaging modality in liver transplant candidates, and its use can be cautiously expanded to liver transplant candidates with concomitant renal insufficiency.

Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database.

PURPOSE: Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables. MATERIALS AND METHODS: We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort. RESULTS: Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214. CONCLUSIONS: Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.

Medical students impact laparoscopic surgery case time.

BACKGROUND: Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS: Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS: This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

Can we become better robot surgeons through simulator practice?

INTRODUCTION: There is significant growth in the use of the robotic surgery platform in the general surgery community. Current pre-requisites for robot surgery training include performing basic tasks on a simulator and achieving a minimum overall score for each task. However, there is limited information about these tasks related to performance and time required to become proficient. We focused on critical tasks that have the highest potential for preventing inadvertent injuries, and constructed models to predict how many attempts would be needed to master the tasks depending on the user's initial attempt. METHODS AND PROCEDURES: This study was conducted using de-identified data collected over 12 months from the dV-Trainers® simulator at our institution. We analyzed tasks used in institutional surgical robot credentialing that focused on camera manipulation and energy use. Data were extracted from the Camera Targeting, Energy Dissection, and Energy Switching exercises focusing on individual metrics such as Time to Complete Exercise, Economy of Motion, Misapplied Energy Time, and Blood Volume Loss. Mixed linear models looking at sequential attempts and specific performance metrics were constructed using IBM SPSS Statistics version 20. RESULTS: Over 26,000 overall minutes of recorded use was logged in our simulator by more than 30 unique users across all exercises. An average of 15 users performed each of the analyzed exercises, with an average of eight attempts per exercise. Based on our models, on average most users would need four to five attempts to achieve 80 % proficiency for any given metric. CONCLUSION: Virtual reality robotic simulators such as the dv-Trainer® can be used by general surgeons to become better robotic surgeons. Our data suggests that it can be used by a surgeon to predict how much time and effort one would need to spend on the simulator in order to become proficient with the robot, especially in critical metrics such as camera manipulation and energy application. Surgeons who require more attempts to successfully complete tasks may want to consider additional training methods, such as proctoring or hands-on laboratories, to improve robot surgery proficiency.

Cost comparison analysis of open versus laparoscopic distal pancreatectomy.

BACKGROUND: In comparison with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) is associated with fewer complications and shorter hospital stays, but comparative cost data for the two approaches are limited. METHODS: Records of all distal pancreatectomies carried out from January 2009 to June 2013 were reviewed and stratified according to operative complexity. Patient factors and outcomes were recorded. Total variable costs (TVCs) were tabulated for each patient, and stratified by category [e.g. 'floor', 'operating room' (OR), 'radiology']. Costs for index admissions and 30-day readmissions were compared between LDP and ODP groups. RESULTS: Of 153 procedures, 115 (70 LDP, 45 ODP) were selected for analysis. The TVC of the index admission was US$3420 less per patient in the LDP group (US$10 480 versus US$13 900; P = 0.06). Although OR costs were significantly greater in the LDP cohort (US$5756 versus US$4900; P = 0.02), the shorter average hospitalization in the LDP group (5.2 days versus 7.7 days; P = 0.01) resulted in a lower overall cost. The total cost of index hospitalization combined with readmission was significantly lower in the LDP cohort (US$11 106 versus US$14 803; P = 0.05). CONCLUSIONS: In appropriately selected patients, LDP is more cost-effective than ODP. The increased OR cost associated with LDP is offset by the shorter hospitalization. These data clarify targets for further cost reductions.

Evaluation of clinical outcomes of prophylactic versus preemptive cytomegalovirus strategy in liver transplant recipients.

Cytomegalovirus (CMV) is a major cause of morbidity and mortality following solid organ transplantation (SOT). Two strategies, prophylactic, and preemptive have emerged for the prevention of CMV infection and disease after SOT. This retrospective chart review of two liver transplant cohorts: prophylactic and preemptive, compares the clinical impact of transitioning from prophylactic to preemptive strategy. The primary outcome is the incidence of CMV viremia at 3-and 6-months post-transplant. Secondary outcomes include: incidence of CMV tissue-invasive disease, acute cellular rejection, leukopenia and neutropenia, opportunistic infection rates, hospital readmission rates, and mortality at 3-and 6-months post-transplant. A total of 109 patients were included in the analysis. The incidence of CMV viremia was 4.9% and 50.0% (P < 0.001) in the prophylactic versus preemptive cohort, respectively, at 3 months post-transplant. The incidence of CMV viremia was 24.6% and 8.3% (P = 0.026) in the prophylactic versus preemptive cohort, respectively, at 6 months post-transplant. There were no statistical significant differences in the secondary outcomes between both cohorts. In conclusion, there is a statistical significant difference in time to onset of CMV viremia; however, the use of either prophylactic or preemptive strategy was not associated with significant negative clinical outcomes of CMV.

Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy.

BACKGROUND: Prolonged operative duration is associated with increased postoperative morbidity and mortality. Although laparoscopic colectomy (LC) is associated with longer operative duration compared with open colectomy (OC), research shows paradoxically decreased morbidity following LC versus OC. The direct impact of operative duration on postoperative pulmonary complications (PPC) following LC versus OC has not been analyzed. METHODS: We queried the ACS/NSQIP 2009-2010 Public Use File for patients who underwent elective LC and OC. The associations between operative duration and a PPC (pneumonia, intubation >48 h, and unplanned intubation) were evaluated. Multivariable regression models were created to determine the independent effect of operative time on the development of PPC controlling for LC versus OC. RESULTS: A total of 25,419 colectomies (13,741 laparoscopic and 11,678 open) were reviewed; 765 (3 %) patients experienced at least one PPC. Regression modeling demonstrated that for both LC and OC each 60-min increase in operative time up to 480 min was associated with 13 % increased odds of PPC [odds ratio (OR) 1.13; 95 % confidence interval (CI) 1.07-1.19]. Beyond 480 min, each additional 60-min interval was associated with 33 % increased risk of PPC (OR 1.33; 95 % CI 1.12-1.58). Overall, PPCs occurred half as often following LC [270 (2 %) laparoscopic vs. 497 (4.3 %) open; OR 0.45; 95 % CI 0.39-0.53]. CONCLUSIONS: Operative duration is independently associated with increased risk of PPC in patients undergoing LC and OC. However, a laparoscopic approach carries half the absolute risk of PPC and, when safe, should be preferentially utilized despite a potential for prolonged operative duration.

Locoregional recurrence after mastectomy with immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction.

BACKGROUND: The locoregional recurrence (LRR) rate after mastectomy is reported to be similar with immediate reconstruction. We aimed to identify characteristics of LRR after transverse rectus abdominis myocutaneous (TRAM) reconstruction. METHODS: We retrospectively reviewed patients undergoing immediate TRAM reconstruction for breast cancer who were diagnosed with LRR. RESULTS: We identified 18 LRR (4.6 %) in 18 of 390 patients who underwent immediate TRAM reconstructions for breast cancer from 1998 to 2008. The median follow-up was 69.2 months. The mean age at time of mastectomy was 49.5 years. All LRR were detected by physical examination. The LRR occurred in the TRAM subcutaneous tissue (n = 9), five in the ipsilateral axillary lymph node and four in the supraclavicular lymph node. Of the 18 patients who developed LRR, 14 (77.7 %) presented with stage 0-1-2 and 4 (22.2 %) with stage 3 disease at the time of the original mastectomy. The average time for a LRR to present was 35.8 months after initial mastectomy and reconstruction. For patients who initially presented with stage 3 disease, the average time to LRR was shorter (22.9 months). Nine patients (50.0 %) were found to have metastatic disease at the time of the LRR, and 6 (33.3 %) died of disease. CONCLUSIONS: All TRAM LRR were detected by routine physical examination by the patient or the surgeon. Our findings suggest that routine history and clinical breast examination of the breast reconstructed with a TRAM flap along with patient self-awareness are reliable in the diagnosis of LRR.

Prisoner survival inside and outside of the institution: implications for health-care planning.

The life expectancy of persons cycling through the prison system is unknown. The authors sought to determine the 15.5-year survival of 23,510 persons imprisoned in the state of Georgia on June 30, 1991. After linking prison and mortality records, they calculated standardized mortality ratios (SMRs). The cohort experienced 2,650 deaths during follow-up, which were 799 more than expected (SMR = 1.43, 95% confidence interval (CI): 1.38, 1.49). Mortality during incarceration was low (SMR = 0.85, 95% CI: 0.77, 0.94), while postrelease mortality was high (SMR = 1.54, 95% CI: 1.48, 1.61). SMRs varied by race, with black men exhibiting lower relative mortality than white men. Black men were the only demographic subgroup to experience significantly lower mortality while incarcerated (SMR = 0.66, 95% CI: 0.58, 0.76), while white men experienced elevated mortality while incarcerated (SMR = 1.28, 95% CI: 1.10, 1.48). Four causes of death (homicide, transportation, accidental poisoning, and suicide) accounted for 74% of the decreased mortality during incarceration, while 6 causes (human immunodeficiency virus infection, cancer, cirrhosis, homicide, transportation, and accidental poisoning) accounted for 62% of the excess mortality following release. Adjustment for compassionate releases eliminated the protective effect of incarceration on mortality. These results suggest that the low mortality inside prisons can be explained by the rarity of deaths unlikely to occur in the context of incarceration and compassionate releases of moribund patients.

Diversity of release patterns for jail detainees: implications for public health interventions.

OBJECTIVES: We sought to develop a detailed description of the variety of jail release patterns and to learn what factors affect the length of stay (LOS). METHODS: The main data set for the study came from a biennial Bureau of Justice Statistics survey on felony defendants in large urban counties. RESULTS: The median LOS for the felony defendants was 7 days. One quarter of the jails had a median LOS of less than 2 days; median LOS for 75% of the jails was less than 15 days. Median regression showed that male gender, previous arrests, and violent charges were predictive of longer LOS. CONCLUSIONS: The diversity in release patterns among jails has not been previously described. A public health intervention feasible in one jail may not be feasible in another because of the heterogeneity of release patterns. Individual inmate characteristics could predict a slower rate of release.

Renal Safety of Intravenous Gadolinium-enhanced MRI in Patients Following Liver Transplantation.

BACKGROUND: Intravenous contrast-enhanced imaging is invaluable in diagnosing pathology following liver transplantation. Given the potential risk of contrast nephropathy associated with iodinated computed tomography contrast, alternate contrast modalities need to be examined, especially in the setting of renal insufficiency. The purpose of this study was to examine the renal safety of MRI with gadolinium following liver transplantation. METHODS: The study involved a retrospective analysis of 549 cases of abdominal MRI with low-dose gadobenate dimeglumine in liver transplant recipients at a single center. For each case, serum creatinine values before and after the MRI were compared. In addition, cases were analyzed for the development of nephrogenic systemic fibrosis. RESULTS: Pre-MRI creatinine values ranged from 0.32 to 6.57 mg/dL (median, 1.28 g/dL), with 191 cases having values ≥1.5 mg/dL (median, 1.86 g/dL). A comparison of the pre- and post-MRI creatinine values showed no significant difference, including those patients with pre-MRI values ≥1.5 mg/dL (mean change of -0.04 [95% confidence interval, -0.07 to -0.01; P = 0.004]). No cases of nephrogenic systemic fibrosis were noted. CONCLUSIONS: Our findings suggest that, irrespective of baseline renal function, MRI with gadobenate dimeglumine is a nonnephrotoxic imaging modality in liver transplant recipients. Importantly, this intravenous contrast-enhanced imaging modality can be considered in those posttransplant patients who have a contraindication to computed tomography contrast due to renal insufficiency.

Hospitalization Costs After Surgery in High-Risk Patients With Early Stage Lung Cancer.

BACKGROUND: We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection. METHODS: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032-z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher's exact test. Multivariate analysis was performed using a linear regressions model. RESULTS: A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay. CONCLUSIONS: Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients' excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients.

Does length of intubation before tracheostomy affect intensive care unit length of stay?

OBJECTIVE: The purpose of this study was to determine if length of intubation before tracheotomy (LIT) affects length of stay in the intensive care unit (ICU). STUDY DESIGN: This was a retrospective case series of patients who had open tracheotomies at Grady Memorial Hospital by the Oral and Maxillofacial Surgery (OMS) service. Medical records were reviewed to document patient demographic characteristics, etiology for ventilator dependence, and complications. The primary predictor variable was LIT and primary outcome variable was length of stay in ICU after tracheotomy. Statistical analysis was performed (significance P < .05). RESULTS: There were 115 patients (mean age 54 years) included in the study. The majority received tracheotomies because of prolonged mechanical ventilation secondary to a medical comorbidity. Intraoperative complications were cardiac arrest and difficulty accessing trachea. Postoperative complications were bleeding. Postoperatively, most patients were discharged from the ICU or weaned off mechanical ventilation within 5 days. The correlation between LIT and ICU stay was not statistically significant, but the trend was positive. CONCLUSIONS: The results of this study indicate that patients undergoing an earlier tracheotomy were more likely to have an earlier discharge from the ICU.

Solving the Value Equation: Assessing Surgeon Performance Using Risk-Adjusted Quality-Cost Diagrams and Surgical Outcomes.

Quality-cost diagrams have been used previously to assess interventions and their cost-effectiveness. This study explores the use of risk-adjusted quality-cost diagrams to compare the value provided by surgeons by presenting cost and outcomes simultaneously. Colectomy cases from a single institution captured in the National Surgical Quality Improvement Program database were linked to hospital cost-accounting data to determine costs per encounter. Risk adjustment models were developed and observed average cost and complication rates per surgeon were compared to expected cost and complication rates using the diagrams. Surgeons were surveyed to determine if the diagrams could provide information that would result in practice adjustment. Of 55 surgeons surveyed on the utility of the diagrams, 92% of respondents believed the diagrams were useful. The diagrams seemed intuitive to interpret, and making risk-adjusted comparisons accounted for patient differences in the evaluation.

Development and Validation of a Risk Calculator for Renal Complications after Colorectal Surgery Using the National Surgical Quality Improvement Program Participant Use Files.

Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin <3.5 g/dL (OR: 1.8), and emergency operation (OR: 1.5). This final model has an area under the curve (AUC) of 0.79 and was validated with similar excellent discrimination (area under the curve: 0.76). Using this model, a risk calculator was developed with excellent predictive ability for postoperative renal complications in colorectal patients and can be used to aid clinical decision-making, patient counseling, and further research on measures to improve patient care.

Abdominal MRI without Enteral Contrast Accurately Detects Intestinal Fibrostenosis in Patients with Inflammatory Bowel Disease.

Patients with inflammatory bowel disease (IBD) presenting for surgical evaluation require thorough small bowel surveillance as it improves accuracy of diagnosis (ulcerative colitis versus Crohn's) and differentiates those who may respond to nonoperative therapy, preserving bowel length. MRI has not been validated conclusively against histopathology in IBD. Most protocols require enteral contrast. This study aimed to 1) evaluate the accuracy of MRI for inflammation, fibrosis, and extraluminal complications and 2) compare MRI without enteral contrast to standard magnetic resonance enterography. Adults with Crohn's disease or ulcerative colitis who underwent abdominal MRI and surgery were retrospectively reviewed. Of 65 patients evaluated, 55 met inclusion criteria. Overall sensitivity and specificity of MRI for disease involvement localized by segment were 93 per cent (95% confidence interval = 89.4-95.0) and 95 per cent (95% confidence interval = 92.3-97.0), respectively (positive predictive value was 86%, negative predictive value was 98%). Sensitivity and specificity between MRI with and without oral and rectal contrast were similar (96% vs 91% and 99% vs 94%, P > 0.10). As were positive predictive value and negative predictive value (85% vs 96%, P = 0.16; 97% vs 99%, P = 0.42). Magnetic resonance is highly sensitive and specific for localized disease involvement and extraluminal abdominal sequelae of IBD. It accurately differentiates patients who have chronic transmural (fibrotic) disease and thus may require an operation from those with acute inflammation, whose symptoms may improve with aggressive medical therapy alone. MRI without contrast had comparable diagnostic yield to standard magnetic resonance enterography.