Segmental Colectomy in Ulcerative Colitis.

BACKGROUND: Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity. OBJECTIVE: To identify ulcerative colitis patients who underwent segmental colectomy and assess their postoperative and long-term outcomes. DESIGN: Retrospective case series. SETTING: A tertiary-care inflammatory bowel disease center. PATIENTS: Ulcerative colitis patients who underwent surgery between 1995 and 2022. INTERVENTION: Segmental colectomy. MAIN OUTCOME MEASURES: Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates and stoma at follow-up. RESULTS: Fifty-five patients were included [20 (36.4%) female; 67.8 (57.4-77.1) years of age at surgery; body mass index 27.7 (24.2-31.1) kg/m2; median follow-up 37.3 months]. ASA score was III in 32 (58.2%) patients, 48 (87.3%) had at least one comorbidity, 48 (87.3%) had Mayo endoscopic subscore of 0-1. Patients underwent right hemicolectomy (28, 50.9%), sigmoidectomy (17, 30.9%), left hemicolectomy (6, 10.9%), low anterior resection (2, 3.6%), or a non-anatomic resection (2, 3.6%) for; endoscopically unresectable polyps (21, 38.2%), colorectal cancer (15, 27.3%), symptomatic diverticular disease (13, 23.6%), and stricture (6, 10.9%). Postoperative complications occurred in 16 (29.1%) patients [7 (12.7%) Clavien-Dindo Class III-V]. Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. 4 (7.3%) patients underwent subsequent completion proctocolectomy with ileostomy. Six (10.9%) patients had stoma at the follow-up. Two and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively. LIMITATIONS: Retrospective study, small sample size. CONCLUSIONS: Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications for colectomy. See Video Abstract.

Rediversion of the Failing Ileoanal Pouch: First Step in Pouch Salvage?

BACKGROUND: Ileal pouch-anal anastomosis is a technically demanding procedure with many potential complications. Rediversion with an ileostomy is often the first step in pouch salvage; however, it may not be clear if an individual patient will undergo subsequent pouch salvage surgery. We aimed to describe the indications and short- and long-term outcomes of rediversion in our pouch registry. METHODS: We queried our institutional pouch registry for patients who underwent index 2- or 3-stage IPAA and subsequent rediversion at our institution between 1985 and 2022. Pouches constructed elsewhere, rediverted elsewhere, or those patients who underwent pouch salvage/excision without prior rediversion were excluded. Patients were selected for pouch salvage according to the surgeon's discretion. RESULTS: Overall, 177 patients (3.4% of 5207 index pouches) were rediverted. At index pouch, median patient age was 32 years and 50.8% were women. Diagnoses included ulcerative colitis (86.4%), indeterminate colitis (6.2%), familial adenomatous polyposis (4.0%), and others (3.4%). Median time from prior ileostomy closure to rediversion was 7.2 years. Indications for rediversion were inflammatory in 98 (55.4%) and noninflammatory in 79 (44.6%) patients. After rediversion, 52% underwent pouch salvage, 30% had no further surgery, and 18.1% underwent pouch excision. The 5-year pouch survival rates for inflammatory and noninflammatory indications were 71.5% and 94.5%, respectively (P = .02). CONCLUSION: Rediversion of ileoanal pouches is a safe initial strategy to manage failing pouches and is a useful first step in pouch salvage in many patients. Subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.

Rediversion with an ileostomy was a safe, useful first step in pouch salvage, and subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.

Fact or fiction? Does the position of the end-to-end (EEA) stapler spike matter for colorectal anastomoses using a double-stapled technique?

AIM: Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end-to-end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity. METHOD: This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left-sided colon resection with double-stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak. RESULTS: Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end-colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05-0.87, p = 0.03). CONCLUSIONS: For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks.

The Importance of Parental Leave and Lactation Support for Surgeons.

Despite the growing population of surgeons who will spend the bulk of their potential childbearing years in medical school, training, or early in practice, the stigma associated with pregnancy remains. The challenges of childbearing for surgeons also extend to the pregnancy experience from a health perspective including increased rates of infertility, miscarriage, and preterm labor. Given the unique demands of a surgical practice, surgeons may experience pressure to minimize the disruption of their work during and after pregnancy. This may include attempts at carrying a full workload until the day of delivery, reducing the length of planned parental leave, and not requesting accommodations for time to express milk. Concern for discrimination, clinical productivity expectations, and promotion timelines can limit a surgeon's ability to receive pregnancy-related support and adequate parental leave. Though not all surgeons will choose to pursue pregnancy, we must still acknowledge the need to support these individuals. Furthermore, this support should not be limited to the pregnancy alone but include postpartum support including that related to family leave and lactation. Here, we provide an overview of just some of the challenges faced by surgeons in the pursuit of parenthood and present the arguments for accommodations related to pregnancy, parental leave, and lactation.

Comparison of surgeon and pathologist total mesorectal excision grade after rectal cancer resection: A single institution analysis.

BACKGROUND: A Michigan Surgical Quality Collaborative Colorectal Cancer Project initiative sought to increase adoption of surgeon total mesorectal excision (TME) grading through standardized education and synoptic operative reporting. Our study aim was to assess initiative impact and level of agreement between surgeon and pathologist-determined TME grades. METHODS: This is a retrospective comparison of surgeon and pathologist TME grades before and after initiative implementation using a prospectively maintained enhanced recovery colorectal surgery database. RESULTS: There were 112 TMEs before, and 53 TMEs following initiative implementation. There was a significant increase in surgeon TME-grade reporting in the postinitiative period (25.0% pre- vs. 81.1% post-, p < 0.001). Pathologist TME-grade reporting was high in both time periods and there was no significant change (91.1% pre- vs. 88.7% post-, p = 0.84). Surgeon and pathologist agreement was 59.3% in the preinitiative period (Κ "minimal"   0.356) and 65.0% in the postinitiative period (Κ "moderate" = 0.605, p = 0.827). There was no significant association between clinical T-stage and surgeon or pathologist TME grade. CONCLUSION: Surgeon TME grading improves with education and synoptic operative reporting. There is only moderate agreement between surgeon and pathologist, a finding that requires further study. Organized regional initiatives are effective at implementing rectal cancer management quality improvement.

Redo Continent Ileostomy in Patients With IBD: Valuable Lessons Learned Over 25 Years.

BACKGROUND: Patients with IBD with continent ileostomies may require revision surgeries. There remains a paucity of data regarding outcomes after redo continent ileostomy. OBJECTIVE: This study aimed to evaluate patient outcomes after redo continent ileostomy. DESIGN: Retrospective cohort study. SETTINGS: This study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: We identified patients who underwent redo continent ileostomy (defined as neo-pouch construction or major operations changing the pouch configuration) for IBD between 1994 and 2020. MAIN OUTCOME MEASURES: The main outcomes measured were patient demographics, short- and long-term outcomes, and quality of life. RESULTS: A total of 168 patients met inclusion criteria; 102 (61%) were female, the mean age was 51 years (±13.1), and the mean BMI was 24.4 (±3.9). The median time between primary and redo continent ileostomy was 16.8 years. One hundred twenty-two patients (73%) who underwent redo surgery had ulcerative colitis, 36 (21%) had Crohn's disease, and 10 (6%) had indeterminate colitis. Slipped nipple valve and valve stricture were the most common indications for redo continent ileostomy (86%). After a median follow-up of 4 years, 48 patients (29%) required a subsequent reoperation and 27 (16%) had pouch failure requiring pouch excision. The pouch survival rate was 89% at 3 years, 84% at 5 years, and 79% at 10 years. On univariate analysis, a shorter interval between the primary and redo continent ileostomy was associated with long-term pouch failure ( p = 0.003). Cox regression multivariate analysis confirmed that a shorter interval between surgeries was independently associated with pouch failure ( p = 0.014). The mean Cleveland Clinic Global Quality of Life score was 0.61 (± 0.23) among the 70 patients who responded to the questionnaire. LIMITATIONS: The main limitations were that this was a retrospective, single-center study and that it had a low response rate for the Global Quality of Life questionnaire. CONCLUSIONS: Redo continent ileostomy surgery is associated with a long-term pouch retention rate of 79% and satisfactory quality of life. Therefore, redo surgery should be offered to patients who are motivated to keep their continent ileostomy. See Video Abstract at http://links.lww.com/DCR/C87 . REHACER LA ILEOSTOMA CONTINENTE EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL VALIOSAS LECCIONES APRENDIDAS DURANTE AOS: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal con ileostomías continentes pueden requerir cirugías de revisión. Sigue habiendo escasez de datos con respecto a los resultados después de volver a realizar la ileostomía continente.OBJETIVO:Evaluar los resultados después de rehacer la ileostomía continente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Departamento especializado en cirugía colorrectal de alto volumen.PACIENTES:Identificamos pacientes que se sometieron a una nueva ileostomía continente (definida como construcción de una nueva bolsa u operaciones mayores que cambian la configuración de la bolsa) por enfermedad inflamatoria intestinal entre 1994 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Datos demográficos de los pacientes, resultados a corto y largo plazo y calidad de vida.RESULTADOS:Un total de 168 pacientes cumplieron con los criterios de inclusión; 102 (61%) eran mujeres, la edad media fue de 51 años (±13,1) y el IMC medio fue de 24,4 (±3,9). La mediana de tiempo entre la ileostomía primaria y la nueva ileostomía continente fue de 16,8 años. Ciento veintidós pacientes (73%) que se sometieron a una nueva cirugía tenían colitis ulcerosa, 36 (21%) tenían enfermedad de Crohn y 10 (6%) tenían colitis indeterminada. El deslizamiento de la válvula del pezón y la estenosis de la válvula fueron las indicaciones más comunes para rehacer la ileostomía continente (86%). Después de una mediana de seguimiento de 4 años, 48 (29%) pacientes requirieron una reintervención posterior y 27 (16%) tuvieron falla de la bolsa que requirió la escisión de la bolsa. La tasa de supervivencia de la bolsa fue del 89 % a los 3 años, del 84% a los 5 años y del 79% a los 10 años. En el análisis univariable, un intervalo de tiempo más corto entre la ileostomía continente primaria y la nueva se asoció con falla de la bolsa a largo plazo (p = 0,003). El análisis multivariable de regresión de Cox confirmó que el intervalo más corto entre cirugías se asoció de forma independiente con el fracaso de la bolsa (p = 0,014). La puntuación media de la Calidad de Vida Global fue de 0,61 (± 0,23) entre los 70 pacientes que respondieron al cuestionario.LIMITACIONES:Estudio retrospectivo de un solo centro. Baja tasa de respuesta al cuestionario de Calidad de Vida.CONCLUSIÓN:La cirugía de ileostomía continente se asocia con una tasa de retención de la bolsa a largo plazo del 79% y una calidad de vida satisfactoria. Por lo tanto, se debe ofrecer una nueva cirugía a los pacientes que están motivados para mantener su ileostomía continente. Consulte Video Resumen en http://links.lww.com/DCR/C87 . (Traducción-Dr. Felipe Bellolio ).

Predictors and Outcomes of Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy.

BACKGROUND: Preoperative chemoradiation is indicated for clinical stage II and III rectal cancers; however, the accuracy of clinical staging with preoperative imaging is imperfect. OBJECTIVE: The study aimed to better characterize the incidence and management of clinical and pathologic stage discordances in patients who did not receive preoperative chemoradiation. DESIGN: This was a retrospective cohort analysis. SETTINGS: The source of data was the National Cancer Database from 2006 to 2015. PATIENTS: We identified patients who underwent resection with curative intent for clinical stage I rectal adenocarcinoma without preoperative chemotherapy or radiation. MAIN OUTCOME MEASURES: We evaluated the characteristics of "upstaged" patients-those with T3/T4 tumors found on pathology (pathologic stage II) and/or with positive regional nodes in the resection specimen (pathologic stage III) compared with those patients who were not upstaged (pathologic stage I). We then used a mixed-effects multivariable survival model to compare overall survival between these groups. RESULTS: Among 7818 clinical stage I rectal cancer patients who did not receive preoperative therapy, tumor upstaging occurred in 819 (10.6%) and nodal upstaging occurred in 1612 (20.8%). Upstaged patients were more likely than those not upstaged to have higher grade tumors and positive margins. Survival was worse in upstaged patients (hazard ratio [HR], 1.64; 95% CI, 1.4-1.9) but improved among those upstaged patients who received either chemotherapy (HR, 0.71; 95% CI, 0.6-0.9) or chemoradiation (HR, 0.62; 95% CI, 0.5-0.7). LIMITATIONS: In addition to the inherent limitations of a retrospective cohort study, the National Cancer Database does not record functional outcomes, local recurrence, or disease-specific survival, so we are restricted to the evaluation of overall survival as an oncologic outcome. CONCLUSIONS: Inaccurate preoperative staging remains a common clinical challenge in the management of rectal cancer. Survival among upstaged patients is improved among those who receive recommended postoperative chemotherapy and/or chemoradiation, yet many patients do not receive guideline-concordant care. See Video Abstract at https://links.lww.com/DCR/B999 . PREDICTORES Y RESULTADOS DE SOBRE ESTADIFICACIN EN PACIENTES CON CNCER DE RECTO QUE NO RECIBIERON TERAPIA PREOPERATORIA: ANTECEDENTES:La quimio radiación preoperatoria está indicada para los estadios clínicos II y III del cáncer rectal; sin embargo, la precisión de la estadificación clínica con imágenes preoperatorias es imperfecta.OBJETIVO:El objetivo fue mejorar la caracterización de la incidencia y el manejo de la discordancia del estadio clínico y patológico en pacientes que no recibieron quimio radiación preoperatoria.DISEÑO:Este fue un análisis de cohorte retrospectivo.CONFIGURACIÓN:La fuente de datos fue de la Base de datos Nacional del Cáncer entre los años 2006-2015.PACIENTES:Identificamos pacientes que fueron sometidos a resección con intención curativa por adenocarcinoma rectal en estadio clínico I, sin quimioterapia o radiación preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Evaluamos las características de los pacientes "sobre estadificados": aquellos con tumores T3/T4 encontrados en patología (estadio patológico II) y/o con ganglios regionales positivos en la muestra de resección (estadio patológico III), en comparación con aquellos pacientes que no fueron sobre estadificados (estadio patológico I). Luego usamos un modelo de supervivencia multivariable de efectos mixtos para comparar la supervivencia general entre estos grupos.RESULTADOS:De entre 7818 pacientes con cáncer de recto, en estadio clínico I, y que no recibieron tratamiento preoperatorio, se produjo una sobre estadificación tumoral en 819 (10,6%) y una sobre estadificación ganglionar en 1612 (20,8%). Los pacientes sobre estadificados tenían más probabilidades que los no sobre estadificados de tener tumores de mayor grado y márgenes positivos. La supervivencia fue peor en los pacientes sobre estadificados (HR 1,64, IC del 95% [1,4, 1,9]), pero mejoró entre los pacientes sobre estadificados que recibieron quimioterapia (HR 0,71, IC del 95% [0,6, 0,9]) o quimio radiación (HR 0,62, 95% IC [0,5, 0,7]).LIMITACIONES:Además de las limitaciones inherente a un estudio de cohorte de tipo retrospectivo, la Base de datos Nacional del Cáncer no registra resultados funcionales, la recurrencia local o la supervivencia específica de la enfermedad, por lo que estamos restringidos a la evaluación de la supervivencia general como un resultado oncológico.CONCLUSIONES:La estadificación preoperatoria inexacta sigue siendo un desafío clínico común en el tratamiento del cáncer de recto. La supervivencia entre los pacientes con sobre estadificación mejora en aquellos que reciben la quimioterapia y/o quimio radioterapia postoperatoria recomendada, aunque muchos pacientes no reciben atención acorde con las guías. Consulte Video Resumen en http://links.lww.com/DCR/B999 . (Traducción-Dr. Osvaldo Gauto ).

Barriers to high-quality rectal cancer care: A qualitative study.

BACKGROUND: High quality multidisciplinary care improves outcomes for rectal cancer (RC) but is not consistently provided. Our objective was to understand surgeons' barriers to RC care. METHODS: Semi-structured interviews were conducted with 18 surgeons from 10 Michigan hospitals. Reports of hospital performance were shared. Interview transcripts were dual coded; data were reduced into emergent themes; and disagreements were resolved by discussion. RESULTS: Barriers to high quality care included negative attitudes, (resistance to change; not taking responsibility) lack of training/experience, complex care coordination, and financial disincentives. Facilitators included providers' positive attitudes and relationships, training/experience, surgeon leadership (development of protocols), patient-level systems of care (patient navigator), and higher-level support (cancer center reviews quality data). Themes were incorporated into an explanatory framework, with patient, provider, and systems domains. CONCLUSIONS: In this qualitative study of RC surgeons, we identified barriers to and facilitators of high-quality care. The framework developed will facilitate the design of quality improvement interventions.

Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer.

BACKGROUND: Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique. OBJECTIVE: This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading. DESIGN: To test the effect of the program, participants completed a survey before and after participating. SETTINGS: Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project. PARTICIPANTS: Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals. MAIN OUTCOME MEASURES: Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice. RESULTS: A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar. LIMITATIONS: Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible. CONCLUSIONS: Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO. ANTECEDENTES: Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos. OBJETIVO: Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal. DISEO: Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma. MARCO: Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto. PARTICIPANTES: Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales. PRINCIPALES RESULTADOS MEDIDOS: La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido. RESULTADOS: Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea. LIMITACIONES: Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares. CONCLUSIONES: Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Incidence and Efficacy of Stent Placement in Leak Management After Bariatric Surgery: An MBSAQIP Analysis.

OBJECTIVE: The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery. SUMMARY OF BACKGROUND DATA: Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown. METHODS: Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups. RESULTS: A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval -1.59 to 4.20). CONCLUSION: Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.

Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study.

BACKGROUND: Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. OBJECTIVE: We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. DESIGN: This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. SETTINGS: Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. PATIENTS: Patients who underwent rectal cancer resection were included. MAIN OUTCOME MEASURE: The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. RESULTS: Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). LIMITATIONS: This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. CONCLUSIONS: The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.

Completeness of operative reports for rectal cancer surgery.

INTRODUCTION: Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer. METHODS: Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness. RESULTS: In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001). CONCLUSIONS/DISCUSSION: Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery.

Reflections on a leadership development program: Impacts on culture in a surgical environment.

BACKGROUND: Although a growing body of literature has focused on the impacts leadership development programs have had on the individual surgeon, little effort has been focused on understanding the impacts these programs have had on surgical culture. The purpose of this study was to explore the impacts of implementing a leadership development program on the culture of the Department of Surgery at University of Michigan, Ann Arbor. METHODS: Qualitative interviews were conducted with 14 surgery faculty in the first cohort of a leadership development program at University of Michigan. Using NVivo (version 11.4.3; QSR International, Melbourne, Australia), thematic analysis was used to locate, analyze, and report patterns within the data. RESULTS: Thematic analysis demonstrated that participation in a leadership development program influenced surgical culture in the following ways: (1) promoted a more participative leadership style, providing tools for surgeons to create a more collaborative environment; (2) increased the culture of diversity, with leaders in the department valuing a more inclusive and wide range of skill sets; and (3) strengthened the collegial environment as evidenced by improved morale and relationships within the department. In addition, several participants expressed difficulty in teasing out what was a direct benefit of a leadership development program versus what could be attributable to other factors, referred to here as the chicken or egg argument. CONCLUSION: Almost all participants expressed experiencing at least some change that they believed was related to the leadership development program. This research may provide insight into the broader implications that programs like these have on surgical culture.

Clinical and pathological outcomes of induction chemotherapy before neoadjuvant radiotherapy in locally-advanced rectal cancer.

BACKGROUND AND OBJECTIVES: In North America, preoperative combination chemoradiation is the most commonly recommended and utilized approach to locally advanced rectal cancer. There is increasing interest in the use of induction chemotherapy (IC) before radiation and surgery in locally advanced rectal cancer. How widely IC is being used and whether it improves pathologic and oncologic outcomes is unknown. METHODS: We evaluated clinical stage 2 or 3 rectal cancer patients in the National Cancer Database between 2006 and 2015. We identified predictors of use of IC with multivariable logistic regression and compared survival between groups using Cox proportional hazards regression. RESULTS: Among 36 268 patients, IC use increased significantly over time from 5.5% in 2006 to 15.9% in 2015 (P < 0.001). Treatment at a hospital with a high IC rate was an independent predictor of receipt of IC. IC and traditional therapy yielded similar pathologic complete response rates (32.2% vs 30.5%, P = 0.2) and similar 5-year survival (82.4% vs 81.4%, 0.71). CONCLUSIONS: Use of IC for locally advanced rectal cancer has increased significantly. The choice of IC seems to be driven more by institutional and regional practice patterns than clinical characteristics and is not associated with improved pathologic or oncologic outcomes.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection.

BACKGROUND: Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home. OBJECTIVE: We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection. DESIGN: This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns. SETTINGS: Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals. PATIENTS: Patients undergoing colon and rectal resections were included. MAIN OUTCOME MEASURE: The main outcome measure was hospital use patterns of nonhome discharge. RESULTS: Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045). LIMITATIONS: This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size. CONCLUSIONS: This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.