Incremental cost of complications in colectomy: a warranty guided approach to surgical quality improvement.

BACKGROUND: We assessed the warranty cost for colectomy at a single institution, as defined by the additional cost of treating complications distributed across all patients treated. METHODS: All segmental colectomies from July 8 to June 12 were reviewed for 0, 1, 2, and ≥3 complications. Warranty cost is defined as follows: ([mean additional cost of the case with complication(s) - mean base case cost] × number of episodes)/total population. RESULTS: Thousand four hundred twenty-two colectomies were analyzed. The lowest cost case was a laparoscopic resection with 0 complications ($7,739 ± 4,150). Warranty costs were less for laparoscopic versus open colectomy (0 - $0, 1 - $128, 2 - $66, ≥3 - $248 vs 0 - $1,036, 1 - $501, 2 - $520, ≥3 - $1,971). This was true for costs associated with readmission ($303 vs $1,519). Emergency status and elderly status also impacted warranty costs. CONCLUSIONS: The data demonstrate that warranty costs were highest with open colectomy, emergency cases, and the elderly. These data can be used to measure both quality and cost impact of mitigation strategies.

Colonic stents: the modern treatment of colonic obstruction.

Colonic stents traditionally have been used for the management of colorectal cancer, either as a palliative treatment or as a bridge to surgery. More recently, colonic stents have also been advocated as part of the therapy of benign strictures. A number of colonic stents are available worldwide, four of which are made in the USA. These stents are classified as covered or uncovered, with similar clinical applications. Technical and clinical success rates are similar among these different stents, as well as the rate of complications, which mainly consist of obstruction and migration. The deployment systems utilize fluoroscopy, endoscopy, or both. More recently, stents became available that are deployed "through the scope" (TTS) making the procedure faster. However, this advance does not exclude the use of fluoroscopy, particularly in those cases where the direct visualization of the proximal end of the stricture is absent. The increasing experience in the management of colorectal cancer with colonic stents decreases the morbidity and mortality, as well as cost, in comparison with surgical intervention for acute colonic obstruction. Management with colonic stents can also rule out proximal synchronous lesions after initial decompression prior to definitive surgery. Benign conditions may also be treated with stents. A multidisciplinary approach for the use of colonic stents during assessment and management of acute colonic obstruction is necessary in order to achieve a satisfactory outcome, whether that be better quality of life or improved survival.