Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons' Annual Scientific and Tripartite Meeting.

BACKGROUND: Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States. OBJECTIVE: We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias. DESIGN: This was a prospective observational study. SETTING: The study occurred at the 2017 Tripartite Meeting. MAIN OUTCOME MEASURES: The primary outcome measured was the percentage of women in the formal program relative to conference attendees and forms of address. METHODS: Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender. RESULTS: Overall, 31% of meeting attendees who are ASCRS members were women, with higher percentages of women as Candidates (44%) and Members (35%) compared with Fellows (24%). Women comprised 28% of moderators (n = 26) and 28% of speakers (n = 80). The highest percentage of women moderators and speakers was in education (48%) and the lowest was in techniques and technology (17%). In the 41 of 47 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs 54.0%, p = 0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs 66.7%, p = 0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs 59.2%, p = 0.003). LIMITATIONS: Yearly program gender composition may fluctuate. Low numbers in certain areas limit interpretability. Other factors potentially influenced speaker introductions. CONCLUSIONS: Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.

Comparative effectiveness of primary tumor resection in patients with stage IV colon cancer.

BACKGROUND: Although the safety of combination chemotherapy without primary tumor resection (PTR) in patients with stage IV colon cancer has been established, questions remain regarding a potential survival benefit with PTR. The objective of this study was to compare mortality rates in patients who had colon cancer with unresectable metastases who did and did not undergo PTR. METHODS: An observational cohort study was conducted among patients with unresectable metastatic colon cancer identified from the National Cancer Data Base (2003-2005). Multivariate Cox regression analyses with and without propensity score weighting (PSW) were performed to compare survival outcomes. Instrumental variable analysis, using the annual hospital-level PTR rate as the instrument, was used to account for treatment selection bias. To account for survivor treatment bias, in situations in which patients might die soon after diagnosis from different reasons, a landmark method was used. RESULTS: In the total cohort, 8641 of 15,154 patients (57%) underwent PTR, and 73.8% of those procedures (4972 of 6735) were at landmark. PTR was associated with a significant reduction in mortality using Cox regression (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.44-0.47) or PSW (HR, 0.46; 95% CI, 0. 44-0.49). However, instrumental variable analysis revealed a much smaller effect (relative mortality rate, 0.91; 95% CI, 0.87-0.96). Although a smaller benefit was observed with the landmark method using Cox regression (HR, 0.6; 95% CI, 0.55-0.64) and PSW (HR, 0.59; 95% CI, 0.54-0.64), instrumental variable analysis revealed no survival benefit (relative mortality rate, 0.97; 95% CI, 0.87-1.06). CONCLUSIONS: Among patients with unresectable metastatic colon cancer, after adjustment for confounder effects, PTR was not associated with improved survival compared with systemic chemotherapy; therefore, routine noncurative PTR is not recommended. Cancer 2017;123:1124-1133. © 2016 American Cancer Society.

Initiation of a Transanal Total Mesorectal Excision Program at an Academic Training Program: Evaluating Patient Safety and Quality Outcomes.

BACKGROUND: Short-term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States. OBJECTIVE: The aim of this study is to describe outcomes after the initiation of a transanal total mesorectal excision program in the setting of an academic colorectal training program. DESIGN: This is a single-center retrospective review of consecutive patients who underwent transanal total mesorectal excision from December 2014 to August 2016. SETTING: This study was conducted at an academic center with a colorectal residency program. PATIENTS: Patients with benign and malignant diseases were selected. INTERVENTION: All transanal total mesorectal excisions were performed with abdominal and perineal teams working simultaneously. OUTCOME MEASURES: The primary outcomes measured were pathologic quality, length of hospital stay, 30-day morbidity, and 30-day mortality. RESULTS: There were 40 patients (24 male). The median age was 55 years (interquartile range, 46.7-63.4) with a median BMI of 29 kg/m (interquartile range, 24.6-32.4). The primary indication was cancer (n = 30), and tumor height from the anal verge ranged from 0.5 to 15 cm. Eighty percent (n = 24) of the patients who had rectal cancer received preoperative chemoradiation. The most common procedures were low anterior resection (67.5%), total proctocolectomy (15%), and abdominoperineal resection (12.5%). Median operative time was 380 minutes (interquartile range, 306-454.4), with no change over time. For patients with malignancy, the mesorectum was complete or nearly complete in 100% of the specimens. A median of 14 lymph nodes (interquartile range, 12-17) were harvested, and 100% of the rectal cancer specimens achieved R0 status. Median length of stay was 4.5 days (interquartile range, 4-7), and there were 6 readmissions (15%). There were no deaths or intraoperative complications. LIMITATIONS: This study's limitations derive from its retrospective nature and single-center location. CONCLUSIONS: A transanal total mesorectal excision program can be safely implemented in a major academic medical center. Quality outcomes and patient safety depend on a comprehensive training program and a coordinated team approach. See Video Abstract at http://links.lww.com/DCR/A448.

Race not rural residency is predictive of surgical treatment for hepatocellular carcinoma: Analysis of the Texas Cancer Registry.

BACKGROUND AND OBJECTIVES: Rural patients have poor access to specialists and are less likely to receive evidence-based cancer care. We hypothesized that hepatocellular carcinoma (HCC) patients from rural counties in Texas would be less likely to receive surgical therapy than those from urban areas. METHODS: The Texas Cancer Registry was queried (2000-2008). County-level data included "rural or urban" designation and income variables derived by zip code. Surgical intervention included: (i) ablation, (ii) resection-partial or total lobectomy, or (iii) transplantation. A multinomial logistic regression was created to determine predictors of intervention. RESULTS: Five thousand thirty seven HCC patients were identified (86% urban) for study. A multinomial regression demonstrated, older age, African-American race, and lower income reduced the likelihood of ablation. Younger age, female gender, Caucasian, and Asian/other race predicted surgical resection, or transplantation. Hispanic race was associated with lower likelihood of resection (RRR 0.75) and transplantation (RRR 0.74), whereas African-American race was associated with pronounced decrease for transplantation (RRR 0.48). Area of residency was not predictive of intervention. CONCLUSIONS: Rural residency did not decrease the likelihood of surgical intervention for hepatocellular carcinoma. Race and income continue to be associated with significant treatment disparity. Additional investigation should focus on factors that govern the selection of resection or transplantation for potentially eligible patients.

Impact of ileostomy-related complications on the multidisciplinary treatment of rectal cancer.

BACKGROUND: Radical resection is the primary treatment for rectal cancer. When anastomosis is possible, a temporary ileostomy is used to decrease morbidity from a poorly healed anastomosis. However, ileostomies are associated with complications, dehydration, and need for a second operation. We sought to evaluate the impact of ileostomy-related complications on the treatment of rectal cancer. METHODS: We conducted a retrospective study of patients who underwent sphincter-preserving surgery between January 2005 and December 2010 at a tertiary cancer center. The primary outcome was the overall rate of ileostomy-related complications. Secondary outcomes included complications related to ileostomy status, ileostomy closure, anastomotic complications at primary resection, rate of stoma closure, and completion of adjuvant chemotherapy assessed by multivariate logistic regression. RESULTS: Of 294 patients analyzed, 32% (n = 95) were women. Two hundred seventy-one (92%) received neoadjuvant chemoradiation. The median tumor distance from the anal verge was 7 cm (interquartile range 5-10 cm). Two hundred eighty-one (96%) underwent stoma closure at a median of 7 months (interquartile range 5.4-8.3 months). The most common complication related to readmission was dehydration (n = 32-11%). Readmission within 60 days of primary resection was associated with delay in initiating adjuvant chemotherapy (odds ratio 3.01, 95% confidence interval 1.42-6.38, p = 0.004). CONCLUSIONS: Diverting ileostomies created during surgical treatment of rectal cancers are associated with morbidity; however, this is balanced against the risk of anastomosis-related morbidity at rectal resection. Given the potential benefit of fecal diversion, patient-oriented interventions to improve ostomy management, particularly during adjuvant chemotherapy, can be expected to yield marked benefits.

Systematic review of educational interventions for ostomates.

BACKGROUND: Stoma-related complications lead to increased hospital length of stay and readmissions. Although education of new ostomates is widely recommended, there is a lack of data regarding effective evidence-based educational interventions to prevent or decrease these complications. OBJECTIVE: The aim of this study was to systematically review the literature for educational interventions for new ostomates designed to decrease stoma-related complications. DATA SOURCES: PubMed was searched for studies on educational interventions for new ostomates. STUDY SELECTION: Studies were included if they were in English, targeted adult stoma patients, and evaluated an educational intervention at the time of stoma creation. INTERVENTION: Educational interventions were performed. MAIN OUTCOME MEASURES: The outcomes of interest were length of stay, complications, and readmissions. RESULTS: We found 1706 articles of which 7 met the inclusion criteria. Two were randomized controlled trials, and the rest were cohort studies. The overall quality of the studies was low. Each study used a unique intervention. However, all incorporated a specialized colorectal or ostomy nurse. Of the 5 studies that evaluated length of stay, 2 found a reduction in length of stay associated with the intervention, but 3 found no difference. Two studies found a reduction in complications, but 2 found no difference. Of the 3 studies that evaluated readmissions, none found a difference in the intervention group compared with the control group. LIMITATIONS: This study is limited by the search of a single database and the inclusion of only English language studies. CONCLUSION: Education is a key component of patient care; however, evidence to support an improvement in clinical outcomes is lacking. Further study is needed by the use of rigorous designs to craft a feasible educational intervention that will lead to improved patient care and outcomes.

Review of stoma site and midline incisional hernias after stoma reversal.

BACKGROUND: The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. METHODS: A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. RESULTS: Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. CONCLUSION: Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

Impact of intra-operative ketamine on postoperative outcomes in abdominal surgery: a narrative review.

Background and Objective: Ketamine offers a promising solution to common postoperative issues in abdominal surgery, including pain, nausea, opioid use, and opioid-related side effects. The purpose of this literature review is to analyze the benefits and potential adverse effects associated with the intraoperative utilization of ketamine during abdominal surgeries. Methods: A comprehensive search of PubMed and Ovid MEDLINE was conducted by two independent reviewers. Studies were included if they targeted adult patients and evaluated intra-operative use of ketamine for abdominal operations. Key Content and Findings: We identified 13 studies of intraoperative use of ketamine in abdominal surgery. The results of these studies showed improved pain management as demonstrated by lower pain scores, decreased hyperalgesia, and a decreased need for additional analgesics. The results also demonstrated a decrease in opioid consumption during the critical 24-hour postoperative period. However, a few studies reported undesirable side effects such as hallucinations and delirium. Conclusions: The intraoperative use of ketamine holds promise as a valuable adjunct to anesthesia during abdominal surgeries. Studies support its use in improving post-operative pain and decreasing opioid consumption. Due to risks of adverse effects, further studies in larger patient populations may help identify which patients will benefit the most. This review offers a succinct selection of the pertinent literature.

The effect of age on race-related breast cancer survival disparities.

BACKGROUND: Breast cancer survival disparities by race are likely multifactorial. In a small pilot cohort, we demonstrated a statistical interaction between age and race. The purpose of this study was to validate earlier findings in a larger, more diverse cohort and to test the hypothesis that breast cancer survival is influenced by the dependent relationship of age and race. METHODS: We conducted a retrospective analysis of a multi-institutional breast cancer database for patients treated between 1999 and 2009. Study variables included age and disease stage at diagnosis, race, treatment (surgery, chemotherapy, radiotherapy, hormone therapy) and overall survival. Statistical analysis and regression models were performed by Stata software. RESULTS: A total of 9,249 patients were included in this study. African American, Hispanic, and Asian patients were more likely to present at a younger age with metastases. African American and Hispanic race were associated with increased mortality after adjusting for stage, age, and treatment. A 2-way interaction between age and race was identified in the Cox regression model (p < 0.001). To further define this interaction, a postestimation analysis was performed to determine the predicted relative hazard for each race with age fixed at 40, 50, 60, 70, and 80 years. At younger ages, the predicted relative hazard was significantly higher for both African American and Hispanic race. CONCLUSIONS: Despite adjusting for stage and treatment differences, African American and Hispanic race predicted poor survival. The effect of age and treatment on breast cancer survival differs across races. Additional research is needed to accurately determine the reasons for worsened survival.

Interaction between age and race alters predicted survival in colorectal cancer.

BACKGROUND: Racial disparities in colorectal cancer persist. Late stage at presentation and lack of stage-specific treatment may be contributing factors. We sought to evaluate the magnitude of disparity remaining after accounting for gender, stage, and treatment using predicted survival models. METHODS: We used institutional tumor registries from a public health system (two hospitals) and a not-for-profit health system (nine hospitals) from 1995 to 2011. Demographics, stage at diagnosis, treatment, and survival were recorded. Hazard ratios (HRs) and predicted HRs were determined by Cox regression and postestimation analyses. RESULTS: There were 6,990 patients: 55.7 % white, 23.6 % African American, 15.1 % Hispanic, and 5.6 % Asian/other. Predictors of survival were surgery (HR 0.57, 95 % confidence interval [CI] 0.46-0.70), chemotherapy (HR 0.7, 95 % CI 0.62-0.79), female gender (HR 0.87, 95 % CI 0.83-0.90), age (HR 1.04, 95 % CI 1.03-1.05), and African American race (HR 3.6, 95 % CI 1.5-8.4). Balancing for stage, gender, and treatment reduced the predicted HRs for African Americans by 28 % and Hispanics by 17 %. In this model, African American and Hispanics still had the worst predicted HRs at younger ages, but whites had the worst predicted HR after age 75. CONCLUSIONS: Gender, stage, and treatment partially accounted for worsened survival in African Americans and Hispanics at all ages. At younger ages, race-related disparities remained which may reflect tumor biology or other unknown factors. Once gender, stage, and treatment are balanced at older ages, the increased mortality observed in whites may be due to factors such as comorbidities. Further system- and patient-level study is needed to investigate reasons for colorectal cancer survival disparities.

Opioid Prescribing Patterns After Colorectal Resections in the United States of America.

Background The opioid epidemic is a significant source of morbidity and mortality in the United States of America. Minimizing opioid prescribing after operations has become an important component of post-operative care pathways. We hypothesized that opioid prescribing has decreased over time after colorectal resections. Methods This is a retrospective study from 2012 to 2019 using the Optum Clinformatics database (Eden Prairie, MN). We included patients aged 18 years or older who had an elective colorectal resection. Our primary outcome was the rate of opioid prescription at post-operative discharge. Secondary outcomes included the rates of gabapentinoid (GABA) prescribing post-operatively. Results Of 17,900 patients, the most common procedure was sigmoid colectomy (35%). Most procedures were open (N=10,626, 59.4%). The most common indication was benign disease (N=12,439, 69.5%). Post-operative opioid prescribing decreased from 64.4% in 2012 to 46.7% in 2019. In the adjusted model, the odds of post-operative opioid prescription were 37% lower in 2019 than in 2012 (OR, 0.63; 95% CI, 0.56-0.72; p<0.0001). At 60 days and one year post surgery, opioid prescribing decreased from 11.6% and 5.9% in 2012 to 7.2% and 5.2% in 2019 (p<0.0001). At 60 days, gabapentinoid prescribing increased from 2.3% in 2012 to 4.0% in 2019 (p=0.0016). Conclusions Our data show that opioid prescribing is common after colorectal surgery with an overall post-operative prescription rate of 55.8%. The modification of post-operative pathways to include guidance on opioid prescribing and non-opioid alternatives may curb opioid prescribing, decrease the number of new persistent opioid users, and decrease the number of opioids available for diversion.

Getting to the bottom of treatment of rectal prolapse in the elderly: Analysis of the National Surgical Quality Improvement Program (NSQIP).

BACKGROUND: Many approaches to treat rectal prolapse exists, yet little is known regarding their safety in the elderly. METHOD: NSQIP (2008-2014) was queried to identify patients ≥ 70 years who underwent open rectopexy (OR), laparoscopic rectopexy (LR) and perineal rectosigmoidectomy (PR). Patients were selected using NSQIP's estimated probability of morbidity of ≥50th percentile. Outcomes were 30-day mortality and a composite: mortality, septic shock and organ space abscess and fascial dehiscence. RESULTS: Overall, 1361 patients underwent OR(18%), LR(15%) and PR(67%) with no difference in outcomes among 3 approaches. After adjustment of other factors, the composite was associated with PR [OR 2.5, CI 1.1, 5.7] and not with older age [OR 1.3, (CI) 0.7, 2.4]. From 2008 to 2014, LR increased from 11% to 19%; and PR decreased from 75% to 72%. CONCLUSIONS: All 3 surgical approaches carry low morbidity among the sick, elderly. PR remains the predominant approach nationally. A paradigm shift accepting the safety of abdominal approaches is needed. There should also be less focus on age in the decision-making process of surgical treatment.

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. METHODS: Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. RESULTS: Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. CONCLUSION: Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.

Is nighttime the right time? Risk of complications after laparoscopic cholecystectomy at night.

BACKGROUND: Laparoscopic cholecystectomies can be performed at night in high-volume acute care hospitals. We hypothesized that nonelective nighttime laparoscopic cholecystectomies are associated with increased postoperative complications. STUDY DESIGN: We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected on demographics, operative time, time of incision, length of stay, 30-day postoperative complications (ie, bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, and bleeding) and death. Statistical analyses were performed using STATA software (version 12; Stata Corp). RESULTS: During 8 months, 356 patients had nonelective laparoscopic cholecystectomies. A majority were female (n = 289 [81.1%]) and Hispanic (n = 299 [84%]). There were 108 (30%) nighttime operations. There were 29 complications in 18 patients; there were fewer daytime than nighttime patients who had at least 1 complication (4.0% vs 7.4%; p = 0.18). On multivariate analysis, age (odds ratio = 1.06 per year; 95% CI, 1.02-1.10; p = 0.002), case duration (odds ratio = 1.02 per minute; 95% CI, 1.01-1.02; p = 0.001), and nighttime surgery (odds ratio = 3.33; 95% CI, 1.14-9.74; p = 0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs 2 days; p < 0.001). CONCLUSIONS: Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.

Glycemic control and prevention of surgical site infection.

BACKGROUND: Stress hyperglycemia is associated with increased risk of surgical site infections (SSIs). Use of strict or tight glycemic control with intensive insulin therapy to prevent SSIs is controversial. METHODS: Review of pertinent English-language literature. RESULTS: There is a large body of literature supporting an association between stress hyperglycemia and SSIs. The quality of evidence from randomized controlled trials and meta-analyses that strict glycemic control reduces SSIs or any infections is low, and the strength of recommendation for strict glycemic control is weak due to the associated increase in moderate and severe hypoglycemia. CONCLUSION: Current recommendations for glycemic control in surgical patients are informed primarily by trials using intensive insulin therapy in critically ill patients. Further research is necessary to ascertain the optimal glycemic target for non-critically ill patients, to determine if subsets of patients may benefit from strict glycemic control, and to identify alternative methods for treating stress hyperglycemia and explaining the mechanisms by which it increases infectious risk.

What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis?

BACKGROUND: Despite studies reporting successful interventions to increase antibiotic prophylaxis compliance, surgical site infections remain a significant problem. The reasons for this lack of improvement are unknown. This review evaluates the internal and external validity of quality improvement studies of interventions to increase surgical antibiotic prophylaxis compliance. STUDY DESIGN: Three investigators independently performed systematic literature searches and selected eligible studies that evaluated interventions to improve perioperative antibiotic prophylaxis timing, type, and/or discontinuation. Studies published before the Surgical Infection Prevention project inception in 2002 were excluded. Each study was assessed based on modified criteria for evaluating quality improvement studies (Standards for Quality Improvement Reporting Excellence) and for facilitating implementation of evidence into practice (Reach-Efficacy-Adoption-Implementation-Maintenance). RESULTS: Forty-six articles met inclusion criteria; 93% reported improvement in antibiotic prophylaxis compliance. Surgical site infections were evaluated in 50% of studies and 65% reported an improvement. Less than 5% of studies used randomization, allocation concealment, or blinding. Nine percent of studies described efforts to minimize bias in the design results and analysis and 13% described a sample size calculation. Approximately one-third of studies described participant adoption of the intervention (26%), factors affecting generalizability (33%), or implementation barriers (37%). Most studies (80%) used multiple interventions; no single intervention was associated with change in compliance. Studies with the lowest baseline compliance showed the greatest improvement, regardless of the intervention(s). CONCLUSIONS: The methodology and reporting of quality improvement studies on perioperative antibiotic prophylaxis is suboptimal, and factors that would improve generalizability of successful intervention implementation are infrequently reported. Clinicians should use caution in applying the results of these studies to their general practice.

Component separation for complex congenital abdominal wall defects: not just for adults anymore.

PURPOSE: Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. METHODS: After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. RESULTS: Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days-10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3-34 months). CONCLUSION: CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.

Revisiting the effectiveness of interventions to decrease surgical site infections in colorectal surgery: A Bayesian perspective.

OBJECTIVE: To evaluate the evidence for interventions to decrease surgical site infections (SSIs) in colorectal operations using Bayesian meta-analysis. BACKGROUND: Interventions other than appropriate administration of prophylactic antibiotics to prevent SSIs have not been adopted widely, in part because of lack of recommendations for these interventions based on traditional meta-analyses. Bayesian methods can provide probabilities of specific thresholds of benefit, which may be more useful in guiding clinical decision making. We hypothesized that Bayesian meta-analytic methods would complement the interpretation of traditional analyses regarding the effectiveness of interventions to decrease SSIs. METHODS: We conducted a systematic search of the Cochrane database for reviews of interventions to decrease SSIs after colorectal surgery other than prophylactic antibiotics. Traditional and Bayesian meta-analyses were performed using RevMan (Nordic Cochrane Center, Copenhagen, Denmark) and WinBUGS (MRC Biostatistics Unit, Cambridge, UK). Bayesian posterior probabilities of any benefit, defined as a relative risk of <1, were calculated using skeptical, neutral, and enthusiastic prior probabilities. Probabilities were also calculated that interventions decreased SSIs by ≥10%, and ≥20% using neutral prior probability distributions. RESULTS: A total of 9 Cochrane reviews met the search criteria. Using traditional meta-analysis methods, only laparoscopic colorectal surgery resulted in a significant reduction in SSIs and a recommendation for use of the intervention. Using Bayesian analysis, several interventions that did not result in "significant" decreases in SSIs using traditional analytic methods had a >85% probability of benefit. Also, nonuse of 2 interventions (mechanical bowel preparation and adhesive drapes) had a high probability of decreasing SSIs compared with their use. CONCLUSION: Bayesian probabilities and traditional point estimates of treatment effect yield similar information in terms of potential effectiveness. Bayesian meta-analysis, however, provides complementary information on the probability of a large magnitude of effect. The clinical impact of using Bayesian methods to inform decisions about which interventions to institute first or which interventions to combine requires further study.