Navigating Progress: 8-Year Single-Center Experience With Minimally Invasive Proctectomy and IPAA.

BACKGROUND: IPAA has become the criterion standard for treating ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn's colitis. Robotic surgery promises improved postoperative outcomes and decreased length of stay. However, few studies have evaluated the benefits of robotic IPAA compared to laparoscopy. OBJECTIVE: To compare short-term 30-day postoperative outcomes of robotic versus laparoscopic proctectomy with IPAA and diverting loop ileostomy. DESIGN: Retrospective observational study from a single, high-volume center. SETTINGS: Mayo Clinic, Rochester, Minnesota (tertiary referral center for IBD). PATIENTS: All adult patients undergoing minimally invasive proctectomy with IPAA and diverting loop ileostomy between January 2015 and April 2023. MAIN OUTCOME MEASURES: Thirty-day complications, hospital length of stay, estimated blood loss, conversion rate, 30-day readmission, and 30-day reoperation. RESULTS: Two hundred seventeen patients were included in the study; 107 underwent robotic proctectomy with IPAA and diverting loop ileostomy, whereas 110 had laparoscopic proctectomy with IPAA and diverting loop ileostomy. Operating time was significantly longer in the robotic group (263 ± 38 vs 228 ± 75 minutes, p < 0.0001). The robotic group also had lower estimated blood loss (81.5 ± 77.7 vs 126.8 ± 111.0 mL, p = 0.0006) as well as fewer conversions (0% vs 8.2%, p = 0.003). Patients in the robotic group received more intraoperative fluids (3099 ± 1140 vs 2472 ± 996 mL, p = 0.0001). However, there was no difference in length of stay, 30-day morbidity, 30-day readmission, 30-day reoperation, rate of diverting loop ileostomy closure at 3 months, and surgical IPAA complication rate after ileostomy closure. LIMITATIONS: Retrospective design, single-center study, potential bias because of the novelty of the robotic approach, and lack of long-term and quality-of-life outcomes. CONCLUSIONS: Robotic proctectomy with IPAA and diverting loop ileostomy may offer advantages in terms of estimated blood loss and conversion rate while maintaining the benefits of minimally invasive surgery. Further research is needed to evaluate long-term outcomes. See Video Abstract . NAVEGANDO EL PROGRESO EXPERIENCIA DE OCHO AOS EN UN SOLO CENTRO CON PROCTECTOMA MNIMAMENTE INVASIVA Y ANASTOMOSIS ANALBOLSA ILEAL: ANTECEDENTES:La anastomosis anal-bolsa ileal (IPAA) se ha convertido en el estándar de oro para el tratamiento de la colitis ulcerosa, la poliposis adenomatosa familiar y casos seleccionados de colitis de Crohn. La cirugía robótica promete mejores resultados posoperatorios y una menor duración de la estancia hospitalaria. Sin embargo, pocos estudios han evaluado los beneficios de la IPAA robótica en comparación con la laparoscopia.OBJETIVO:Comparar los resultados postoperatorios a corto plazo a 30 días de la proctectomía robótica versus laparoscópica con IPAA e ileostomía en asa de derivación.DISEÑO:Estudio observacional retrospectivo de un único centro de gran volumen.AJUSTES:Mayo Clinic, Rochester, Minnesota (centro terciario de referencia para EII).PACIENTES:Todos los pacientes adultos sometidos a proctectomía mínimamente invasiva con IPAA y DLI entre Enero de 2015 y Abril de 2023.PRINCIPALES MEDIDAS DE RESULTADOS:Complicaciones a los 30 días, duración de la estancia hospitalaria, pérdida de sangre estimada, tasa de conversión, reingreso a los 30 días y reoperación a los 30 días.RESULTADOS:Se incluyeron en el estudio 217 pacientes; 107 se sometieron a proctectomía robótica con IPAA y DLI, mientras que 110 se sometieron a proctectomía laparoscópica con IPAA y DLI. El tiempo operatorio fue significativamente mayor en el grupo robótico (263 ± 38 minutos versus 228 ± 75 minutos, p < 0,0001); la pérdida de sangre estimada (EBL) fue menor en el grupo robótico (81,5 ± 77,7 ml versus 126,8 ± 111,0 ml, p = 0,0006), así como el número de conversiones (0% versus 8,2%, p = 0,003). Los pacientes del grupo robótico recibieron más líquidos intraoperatorios (3099 ± 1140 ml versus 2472 ± 996 ml, p = 0,0001). Sin embargo, no hubo diferencias en la duración de la estancia hospitalaria, la morbilidad a los 30 días, el reingreso a los 30 días, la reoperación a los 30 días, la tasa de cierre del DLI a los tres meses y la tasa de complicaciones quirúrgicas de la IPAA después del cierre de la ileostomía.LIMITACIONES:Diseño retrospectivo, estudio unicéntrico, posible sesgo debido a la novedad del enfoque robótico, falta de resultados a largo plazo y de calidad de vida.CONCLUSIONES:La proctectomía robótica con IPAA y DLI puede ofrecer ventajas en términos de EBL y tasa de conversión, manteniendo al mismo tiempo los beneficios de la cirugía mínimamente invasiva. Se necesita más investigación para evaluar los resultados a largo plazo. (Traducción-Dr. Yesenia Rojas-Khalil ).

Timing and Location of Venous Thromboembolisms After Surgery for Inflammatory Bowel Disease.

INTRODUCTION: Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear. METHODS: Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively. RESULTS: In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD. CONCLUSIONS: The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events.

Tradition Versus Value: Is There Utility in Protocolized Postoperative Laboratory Testing After Elective Colorectal Surgery?

OBJECTIVE: Determine if routine ordering of postoperative day 1 (POD 1) serum laboratory tests after elective colorectal surgery are clinically warranted and valuable given the associated costs of these lab tests. SUMMARY OF BACKGROUND DATA: Routine postoperative serum laboratory tests are a part of many colorectal surgery order sets. Whether these protocolized lab tests represent cost-effective care is unknown. METHODS: Patients undergoing elective colorectal surgery between January 1, 2015 and December 31, 2017 at our institution were identified. The protocolized POD 1 lab tests obtained as part of the postoperative order set were reviewed to determine the rate of abnormal values and any intervention in response. Costs associated with protocolized laboratory testing were calculated using dollar amounts representing 2017 outpatient Medicare reimbursement. RESULTS: A total of 2252 patients were identified with 8205 total lab test values. Of these, only 4% were abnormal (3% of hemoglobin values, 6% of creatinine values, 3% of potassium of values, and 3% of glucose values), and only 1% were actively intervened upon. The total aggregate cost of the protocolized POD 1 laboratory tests in these years was $64,000 based on Medicare outpatient reimbursement dollars. CONCLUSIONS: Routine POD 1 lab tests after elective colorectal surgery are rarely abnormal, and they even less frequently require active intervention beyond rechecking. This results in increased resource utilization and cost of care without appreciable impact on clinical care, and is not cost-effective. Protocolized POD 1 laboratory testing should be replaced with clinically-based criteria to trigger serum laboratory investigations.

microRNA overexpression in slow transit constipation leads to reduced NaV1.5 current and altered smooth muscle contractility.

OBJECTIVE: This study was designed to evaluate the roles of microRNAs (miRNAs) in slow transit constipation (STC). DESIGN: All human tissue samples were from the muscularis externa of the colon. Expression of 372 miRNAs was examined in a discovery cohort of four patients with STC versus three age/sex-matched controls by a quantitative PCR array. Upregulated miRNAs were examined by quantitative reverse transcription qPCR (RT-qPCR) in a validation cohort of seven patients with STC and age/sex-matched controls. The effect of a highly differentially expressed miRNA on a custom human smooth muscle cell line was examined in vitro by RT-qPCR, electrophysiology, traction force microscopy, and ex vivo by lentiviral transduction in rat muscularis externa organotypic cultures. RESULTS: The expression of 13 miRNAs was increased in STC samples. Of those miRNAs, four were predicted to target SCN5A, the gene that encodes the Na+ channel NaV1.5. The expression of SCN5A mRNA was decreased in STC samples. Let-7f significantly decreased Na+ current density in vitro in human smooth muscle cells. In rat muscularis externa organotypic cultures, overexpression of let-7f resulted in reduced frequency and amplitude of contraction. CONCLUSIONS: A small group of miRNAs is upregulated in STC, and many of these miRNAs target the SCN5A-encoded Na+ channel NaV1.5. Within this set, a novel NaV1.5 regulator, let-7f, resulted in decreased NaV1.5 expression, current density and reduced motility of GI smooth muscle. These results suggest NaV1.5 and miRNAs as novel diagnostic and potential therapeutic targets in STC.

Improving the rate of surgical normothermia in gynecologic surgery.

OBJECTIVE: To increase the rate of normothermia (core temperature ≥ 36 °C) in patients undergoing gynecologic surgery. METHODS: The rate of surgical normothermia was evaluated in a single institution. A two-phase quality improvement project was undertaken; Phase 1 included the use of intra-operative room temperature regulation and intra-operative patient warming and Phase 2 included pre-operative patient warming. Clinical characteristics, median temperatures, and rate of normothermia were abstracted for patients in each phase. Cohorts were compared using chi-square and t-tests. RESULTS: The project was performed in two phases, each with a historic and intervention cohort. There were 503 patients in the historical cohort and 636 patients in the intervention cohort in phase 1; there were 291 patients in the historical cohort and 259 patients in the intervention cohort for Phase 2. Patient characteristics and anesthetic type and duration did not differ between cohorts. After intra-operative temperature regulation and patient warming in Phase 1, significantly more patients achieved normothermia (79% versus 68%, P < 0.0001). However operating room staff were more likely to rate the temperature as very hot in 40% of cases post-intervention, compared to only 2% historically. In Phase 2, after the intervention of pre-warming patients, there was no difference in achieving normothermia, 78% versus 83%, P = 0.09. Staff had no statistical difference in personal comfort with the temperature, however did feel efforts were very effective more frequently, 7.7% historic versus 32.7% post-intervention, P < 0.0001. CONCLUSIONS: Quality improvement methodology can be applied to pre- and intra-operative decision making to improve rates of surgical patient normothermia.

From Data to Practice: Increasing Awareness of Opioid Prescribing Data Changes Practice.

: We hypothesized that the recent attention to the opioid epidemic, combined with internal dissemination of data on prescribing practices, impacted our institution's opioid prescribing at discharge from elective surgery. We reviewed our recent practice to assess whether this increasing awareness resulted in reductions of opioid prescriptions for patients with acute pain. Data on prescribing for patients undergoing elective surgery between 2016 and early 2017 demonstrated that opioid prescribing practices have improved in the recent era without an observed increase in refill rates. Although additional work is needed to further improve standardization and reduce opioid prescribing, these data suggest that increased awareness may be an important first step in improving opioid prescribing practices.

Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery.

OBJECTIVE: The aim of this study was to conduct a prospective, multicenter survey of patients regarding postoperative opioid use to inform development of standardized, evidence-based, procedure-specific opioid prescribing guidelines. SUMMARY OF BACKGROUND DATA: Previous work has shown significant variation in the amount of opioids prescribed after elective procedures, calling for optimization of prescribing. METHODS: Adults (n = 3412) undergoing 25 elective procedures were identified prospectively from 3 academic centers (March 2017 to January 2018) to complete a 29-question telephone interview survey 21 to 35 days post-discharge (n = 688 not contacted, n = 107 refused). Discharge opioids were converted into Morphine Milligram Equivalents (MMEs). RESULTS: Of the 2486 patients who completed the survey, 91.2% received opioids at discharge [median 225 (interquartile range, IQR 125 to 381) MME]. A median of 43 (0 to 184) MMEs were consumed after discharge with 77.3% of patients having leftover opioids at the time of the survey. In total, 61.5% of prescribed opioids were unused; 31.4% of patients used no opioids, and 52.6% required <50 MME. Overall, 90.6% of patients were satisfied with their postdischarge pain control. While 28.3% reported being prescribed too many opioids, 9.0% felt they were not prescribed enough. Only 9.6% of patients disposed of remaining opioids. Of the 2068 opioid-naive respondents (83.2%), 33.6% consumed no opioids (range 5.2% to 80.0% by procedure) and 57.0% (65.7% nonorthopedic) consumed <50 MME. Utilization data and predictors of low/high opioid consumption informed development of postoperative prescribing guidelines. CONCLUSION: A large proportion of postoperative patients reported using no or few opioids following discharge. Guidelines were developed to minimize opioid prescribing and identify patients requiring low doses or additional multimodal pain control.

Assessing the Safety of Overlapping Surgery at a Children's Hospital.

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Infectious Surgical Complications are Not Dichotomous: Characterizing Discordance Between Administrative Data and Registry Data.

OBJECTIVE: To characterize reasons for discordance between administrative data and registry data in the determination of postoperative infectious complications. BACKGROUND: Data regarding the occurrence of postoperative surgical complications are identified through either administrative or registry data. Rates of complications vary significantly between these two types of data; the reasons for this are not well-understood. METHODS: The occurrence of 30-day inpatient infectious complications (pneumonia, sepsis, surgical site infection, and urinary tract infection) was compared between the NSQIP and administrative mechanisms at 4 academic hospitals between 2012 and 2014. In each situation where the NSQIP and administrative data were discordant regarding the occurrence of a specific complication, a 2-clinician chart abstraction was performed to characterize the reasons for discordance as (i) administrative coding error, (ii) NSQIP coding error, (iii) "question of criteria", where the discordance was the result of differences in criteria, or (iv) "dually incorrect", where both data sources coded the complication incorrectly. RESULTS: The cohort included 19,163 patients undergoing surgery in 4 different academic hospitals. Rates of infectious complications varied up to 5-fold between the two data sources. A total of 717 discordant complications were identified. Of these, the greatest portion (43%) was due to "question of criteria," followed by administrative coding error (37%), NSQIP error (15%), and dually incorrect (5%). CONCLUSIONS: With a goal of improving existing mechanisms for measuring surgical quality, definitions for the occurrence of a postoperative complication need to be developed and applied consistently. Progress toward this goal will enable patients and payers to better take advantage of recent advances in healthcare data transparency.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS.

OBJECTIVE: The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL. METHODS: Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality). RESULTS: Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes. CONCLUSION: Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery. ABBREVIATIONS: HbA1c = glycated hemoglobin A1c; IQR = interquartile range.

Safety of Overlapping Surgery at a High-volume Referral Center.

OBJECTIVE: To compare safety profiles of overlapping and nonoverlapping surgical procedures at a large tertiary-referral center where overlapping surgery is performed. BACKGROUND: Surgical procedures are frequently performed as overlapping, wherein one surgeon is responsible for 2 procedures occurring at the same time, but critical portions are not coincident. The safety of this practice has not been characterized. METHODS: Primary analyses included elective, adult, inpatient surgical procedures from January 2013 to September 2015 available through University HealthSystem Consortium. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure type. Confirmatory analyses from the American College of Surgeons-National Surgical Quality Improvement Program investigated elective surgical procedures from January 2011 to December 2014. We compared outcomes mortality and length of stay after adjustment for registry-predicted risk, case-mix, and surgeon using mixed models. RESULTS: The University HealthSystem Consortium sample included 10,765 overlapping cases, of which 10,614 (98.6%) were matched to 16,111 nonoverlapping procedures. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures; 95% confidence interval, CI 1.23-3.73; P = 0.007) and length of stay was no different (+1% for nonoverlapping cases; 95% CI, -1% to +2%; P = 0.50). In confirmatory analyses, 93.7% (3712/3961) of overlapping procedures matched to 5,637 nonoverlapping procedures. The 30-day mortality (adjusted OR = 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13-3.57; P = 0.65), morbidity (adjusted OR = 1.11; 95% CI, 0.92-1.35; P = 0.27) and length of stay (-4% for nonoverlapping; 95% CI, -4% to -3%; P < 0.001) were not clinically different. CONCLUSIONS: These findings from administrative and clinical registries support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers.

Wide Variation and Overprescription of Opioids After Elective Surgery.

OBJECTIVE: We aimed to identify opioid prescribing practices across surgical specialties and institutions. BACKGROUND: In an effort to minimize the contribution of prescription narcotics to the nationwide opioid epidemic, reductions in postoperative opioid prescribing have been proposed. It has been suggested that a maximum of 7 days, or 200 mg oral morphine equivalents (OME), should be prescribed at discharge in opioid-naïve patients. METHODS: Adults undergoing 25 common elective procedures from 2013 to 2015 were identified from American College of Surgeons National Surgical Quality Improvement Program data from 3 academic centers in Minnesota, Arizona, and Florida. Opioids prescribed at discharge were abstracted from pharmacy data and converted into OME. Wilcoxon Rank-Sum and Kruskal-Wallis tests assessed variations. RESULTS: Of 7651 patients, 93.9% received opioid prescriptions at discharge. Of 7181 patients who received opioid prescriptions, a median of 375 OME (interquartile range 225-750) were prescribed. Median OME varied by sex (375 men vs 390 women, P = 0.002) and increased with age (375 age 18-39 to 425 age 80+, P < 0.001). Patients with obesity and patients with non-cancer diagnoses received more opioids (both P < 0.001). Subset analysis of the 5756 (75.2%) opioid-naïve patients showed the majority received >200 OME (80.9%). Significant variations in opioid prescribing practices were seen within each procedure and between the 3 medical centers. CONCLUSIONS: The majority of patients were overprescribed opioids. Significant prescribing variation exists that was not explained by patient factors. These data will guide practices to optimize opioid prescribing after surgery.

Analysis of Postoperative Venous Thromboembolism in Patients With Chronic Ulcerative Colitis: Is It the Disease or the Operation?

BACKGROUND: Patients with IBD have a higher baseline risk of venous thromboembolism, which further increases with surgery. Therefore, extended venous thromboembolism chemoprophylaxis has been suggested in certain high-risk cohorts. OBJECTIVE: The purpose of this study was to determine whether the underlying diagnosis, operative procedure, or both influence the incidence of postoperative venous thromboembolism. DESIGN: This was a retrospective review. SETTINGS: The American College of Surgeons-National Surgical Quality Improvement Project database was analyzed. PATIENTS: The NSQIP database was queried for patients with chronic ulcerative colitis and non-IBD undergoing colorectal resections using surgical Current Procedural Terminology codes modeled after the 3 stages used for the surgical management of chronic ulcerative colitis from 2005 to 2013. MAIN OUTCOME MEASURES: We measured 30-day postoperative venous thromboembolism risk in patients with chronic ulcerative colitis based on operative stage and risk factors for development of venous thromboembolism. RESULTS: A total of 18,833 patients met inclusion criteria, with an overall rate of venous thromboembolism of 3.8. Among procedure risk groups, venous thromboembolism rates were high risk, 4.4%; intermediate risk, 1.6%; and low risk, 0.7% (across risk groups, p < 0.01). Emergent case subjects exhibited a higher rate of venous thromboembolism than their elective counterparts (6.9% vs 3.1%). Factors significantly associated with venous thromboembolism on adjusted analysis included emergent risk case (adjusted OR = 7.85), high-risk elective case (adjusted OR = 5.07), intermediate-risk elective case (adjusted OR = 2.69), steroid use (adjusted OR = 1.54), and preoperative albumin <3.5 g/dL (adjusted OR = 1.45). LIMITATIONS: Because of its retrospective nature, correlation between procedures and venous thromboembolism risk can be demonstrated, but causation cannot be proven. In addition, data on inpatient and extended venous thromboembolism prophylaxis use are not available. CONCLUSIONS: Emergent status and operative procedure are the 2 highest risk factors for postoperative venous thromboembolism. Extended venous thromboembolism prophylaxis might be appropriate for patients undergoing these high-risk procedures or any emergent colorectal procedures. See Video Abstract at http://links.lww.com/DCR/A339.

Using an Electronic Perioperative Documentation Tool to Identify Returns to Operating Room (ROR) in a Tertiary Care Academic Medical Center.

BACKGROUND: The metric "Unplanned returns to operating room (ROR)" is being tracked in surgical quality dashboards; 70% of unplanned RORs may be related to surgical complications. With increasing regionalization of trauma and complex surgical care at tertiary care academic centers, it is unclear if a simple ROR metric is a valid assessment of surgical quality at such centers. METHOD: A real-time electronic tool was used to identify all RORs-planned and unplanned-in a high-volume, high-complexity academic surgical practice at Mayo Clinic-Rochester within 45 days of the index operation. Analysis by ROR type and indication was performed. RESULTS: During the analysis period (June 2014-February 2015) 44,031 operations were performed, with 5,552 subsequent RORs (13%). Of all RORs, 51% (n = 2,818) were planned staged returns, 29% (n = 1,589) were unrelated, 15% (n = 830) were unplanned and 6% (n = 315) were planned because of previous complications. Overall, unplanned reoperations were uncommon (n = 830, 2% of all operations). The most common indications for unplanned RORs included "other" (32%, n = 266), bleeding related (24%, n = 198) and wound complications (20%, n = 166). CONCLUSION: In a high-volume, high-complexity academic surgical practice, RORs occurred after 13% of cases. Unplanned returns were infrequent and usually were associated with complications; most RORs were planned staged or unrelated returns. A simple ROR metric that does not consider planned/unrelated returns is likely not a valid surgical quality measure. Electronic tools designed specifically to identify in real-time RORs, associated indication, and clinical validation should provide more reliable data for public reporting and quality improvement efforts.

Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery.

PURPOSE: The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) is a clinically-derived, validated tool to track outcomes in surgery. The Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are a set of computer algorithms run on administrative data to identify adverse events. The purpose of this study is to compare complications following orthopedic surgery identified by ACS-NSQIP and AHRQ-PSI. METHODS: Patients between 2010 and 2012 who underwent orthopedic procedures (arthroplasty, spine, trauma, foot and ankle, hand, and upper extremity) at our tertiary-care, academic institution were identified (n = 3,374). Identification of inpatient adverse events by AHRQ-PSI in the cohort was compared with 30-day events identified by ACS-NSQIP. Adverse events common to both AHRQ-PSI and ACS-NSQIP were infection, sepsis, venous thromboembolism, bleeding, respiratory failure, wound disruption, and renal failure. Concordance between AHRQ-PSI and ACS-NSQIP for identifying adverse events was examined. RESULTS: A total of 729 adverse events (21.6%) were identified in the cohort using ACS-NSQIP methodology and 35 adverse events (1.0%) were found using AHRQ-PSI. Only 12 events were identified by both methodologies. The most common complication was bleeding in ACS-NSQIP (18.1%) and respiratory failure in AHRQ-PSI (0.53%). The overlap was highest for venous thromboembolic events. There was no overlap in adverse events for 5 of the 7 categories of adverse events. CONCLUSIONS: A large discrepancy was observed between adverse events reported in ACS-NSQIP and AHRQ-PSI. A large percentage of clinically important adverse events identified in ACS-NSQIP were missed in AHRQ-PSI algorithms. The ability of AHRQ-PSI for detecting adverse events varied widely with ACS-NSQIP. CLINICAL RELEVANCE: AHRQ-PSI algorithms currently are insufficient to assess the quality of orthopedic surgery.

Cost-effectiveness of alternative colonoscopy surveillance strategies to mitigate metachronous colorectal cancer incidence.

BACKGROUND: The incidence of metachronous colorectal cancer (MCRC) among colorectal cancer (CRC) survivors varies significantly, and the optimal colonoscopy surveillance practice for mitigating MCRC incidence is unknown. METHODS: A cost-effectiveness analysis was used to compare the performances of the US Multi-Society Task Force guideline and all clinically reasonable colonoscopy surveillance strategies for 50- to 79-year-old posttreatment CRC patients with a computer simulation model. RESULTS: The US guideline [(1,3,5)] recommends the first colonoscopy 1 year after treatment, whereas the second and third colonoscopies are to be repeated at 3- and 5-year intervals. Some promising alternative cost-effective strategies were identified. In comparison with the US guideline, under various scenarios for a 20-year period, 1) reducing the surveillance interval of the guideline after the first colonoscopy by 1 year [(1,2,5)] would save up to 78 discounted life-years (LYs) and prevent 23 MCRCs per 1000 patients (incremental cost-effectiveness ratio [ICER] ≤ $23,270/LY), 2) reducing the intervals after the first and second negative colonoscopies by 1 year [(1,2,4)] would save/prevent up to 109 discounted LYs and 36 MCRCs (ICER ≤ $52,155/LY), and 3) reducing the surveillance intervals after the first and second negative colonoscopy by 1 and 2 years [(1,2,3)] would save/prevent up to 141 discounted LYs and 50 MCRCs (ICER ≤ $63,822/LY). These strategies would require up to 1100 additional colonoscopies per 1000 patients. Although the US guideline might not be cost-effective in comparison with a less intensive oncology guideline [(3,3,5); the ICER could be as high as $140,000/LY], the promising strategies would be cost-effective in comparison with such less intensive guidelines unless the cumulative MCRC incidence were very low. CONCLUSIONS: The US guideline might be improved by a slight increase in the surveillance intensity at the expense of moderately increased cost. More research is warranted to explore the benefits/harms of such practices. Cancer 2016;122:2560-70. © 2016 American Cancer Society.

Effect of Hospital Case Mix on the Hospital Consumer Assessment of Healthcare Providers and Systems Star Scores: Are All Stars the Same?

OBJECTIVE: We aimed to evaluate variations in patient experience measures across different surgical specialties and to assess the impact of further case-mix adjustment. BACKGROUND: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patients' hospital experiences that directly influence Medicare reimbursement. METHODS: All adult surgical inpatients meeting criteria for HCAHPS sampling from 2013 to 2014 at a single academic center were identified. HCAHPS measures were analyzed according to published top-box and Star-rating methodologies, and were dichotomized ("high" vs "low"). Multivariable logistic regression was used to identify independent associations of high patient scores on various HCAHPS measures with specialty, diagnosis-related group complexity, cancer diagnosis, sex, and emergency admission after adjusting for HCAHPS case-mix adjusters (education, overall health status, language, and age). RESULTS: We identified 36,551 eligible patients, of which 30.8% (n = 11,273) completed HCAHPS. Women [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.72-0.85, P < 0.001], complex cases (OR 0.90, 95% CI 0.82-0.99, P = 0.02), and emergency admissions (OR 0.67, 95% CI 0.55-0.82, P < 0.001) had lesser Star scores on adjusted analysis, whereas patients with a cancer diagnosis had greater Star scores (OR 1.15, 95% CI 1.03-1.29, P = 0.01). Using general surgery as the reference, the Star scores varied significantly across 12 specialties (range OR 0.65 for plastics to 1.29 for transplant surgery). Patient responses to individual composite scores (pain, care transition, physician, and nurse) varied by specialty. CONCLUSIONS: HCAHPS case-mix adjustment does not include adjustment for specialty or diagnosis, which may result in artificially lower scores for centers that provide a high level of complex care. Further research is needed to ensure that the HCAHPS is an unbiased comparison tool.

Anesthesia Care Transitions and Risk of Postoperative Complications.

BACKGROUND: A patient undergoing surgery may receive anesthesia care from several anesthesia providers. The safety of anesthesia care transitions has not been evaluated. Using unconditional and conditional multivariable logistic regression models, we tested whether the number of attending anesthesiologists involved in an operation was associated with postoperative complications. METHODS: In a cohort of patients undergoing elective colorectal surgical in an academic tertiary care center with a stable anesthesia care team model participating in the American College of Surgeons National Surgical Quality Improvement Program, using unconditional and conditional multivariable logistic regression models, we tested adjusted associations between numbers of attending anesthesiologists and occurrence of death or a major complication (acute renal failure, bleeding that required a transfusion of 4 units or more of red blood cells within 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours or longer, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, stroke, wound disruption, deep or organ-space surgical-site infection, superficial surgical-site infection, sepsis, septic shock, systemic inflammatory response syndrome). RESULTS: We identified 927 patients who underwent elective colectomy of comparable surgical intensity. In all, 71 (7.7%) patients had major nonfatal complications or death. One anesthesiologist provided care for 530 (57%) patients, 2 anesthesiologists for 287 (31%), and 3 or more for 110 (12%). The number of attending anesthesiologists was associated with increased odds of postoperative complication (unadjusted odds ratio [OR] = 1.52, 95% confidence interval [CI] 1.18-1.96, P = 0.0013; adjusted OR = 1.44, 95% CI 1.09-1.91, P = 0.0106). In sensitivity analyses, occurrence of a complication was significantly associated with the number of in-room providers, defined as anesthesia residents and nurse anesthetists (adjusted OR = 1.39, 95% CI 1.01-1.92, P = 0.0446) and for all anesthesia providers (adjusted OR = 1.58, 95%CI 1.20-2.08, P = 0.0012). Findings persisted across multiple, alternative adjustments, sensitivity analyses, and conditional logistic regression with matching on operative duration. CONCLUSIONS: In our study, care by additional attending anesthesiologists and in-room providers was independently associated with an increased odds of postoperative complications. These findings challenge the assumption that anesthesia transitions are care neutral and not contributory to surgical outcomes.

Ranolazine inhibits voltage-gated mechanosensitive sodium channels in human colon circular smooth muscle cells.

Human jejunum smooth muscle cells (SMCs) and interstitial cells of Cajal (ICCs) express the SCN5A-encoded voltage-gated, mechanosensitive sodium channel NaV1.5. NaV1.5 contributes to small bowel excitability, and NaV1.5 inhibitor ranolazine produces constipation by an unknown mechanism. We aimed to determine the presence and molecular identity of Na(+) current in the human colon smooth muscle and to examine the effects of ranolazine on Na(+) current, mechanosensitivity, and smooth muscle contractility. Inward currents were recorded by whole cell voltage clamp from freshly dissociated human colon SMCs at rest and with shear stress. SCN5A mRNA and NaV1.5 protein were examined by RT-PCR and Western blots, respectively. Ascending human colon strip contractility was examined in a muscle bath preparation. SCN5A mRNA and NaV1.5 protein were identified in human colon circular muscle. Freshly dissociated human colon SMCs had Na(+) currents (-1.36 ± 0.36 pA/pF), shear stress increased Na(+) peaks by 17.8 ± 1.8% and accelerated the time to peak activation by 0.7 ± 0.3 ms. Ranolazine (50 µM) blocked peak Na(+) current by 43.2 ± 9.3% and inhibited shear sensitivity by 25.2 ± 3.2%. In human ascending colon strips, ranolazine decreased resting tension (31%), reduced the frequency of spontaneous events (68%), and decreased the response to smooth muscle electrical field stimulation (61%). In conclusion, SCN5A-encoded NaV1.5 is found in human colonic circular smooth muscle. Ranolazine blocks both peak amplitude and mechanosensitivity of Na(+) current in human colon SMCs and decreases contractility of human colon muscle strips. Our data provide a likely mechanistic explanation for constipation induced by ranolazine.