Surgeon Annual and Cumulative Volumes Predict Early Postoperative Outcomes after Rectal Cancer Resection.

OBJECTIVE: To determine if 5-year surgeon cumulative and annual volumes predict improved early postoperative outcomes in patients with rectal cancer. BACKGROUND: Operative experience has been shown to effect surgical outcomes. The differential role of cumulative versus annual volume has not yet been explored for rectal surgery. METHODS: The Statewide Planning and Research Cooperative System database was used to capture patients undergoing surgery in New York State from 2000 to 2013. A population-based sample of patients undergoing major rectal or rectosigmoid resection as their principal procedure during hospitalization between 2000 and 2013 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Surgeons were identified using a unique physician number from 1995 to 2013. RESULTS: The percentage of surgeries performed by high cumulative/high annual (HC/HA) surgeons increased from 38.3% to 58.4% (P < 0.01) with a simultaneous decrease in that performed by low cumulative/low annual (LC/LA) surgeons (52.5% to 29.8%, P < 0.01). HC/HA volume surgeons had a significantly lower rate of surgical complications (odd ratio = 0.71, 95% confidence interval = 0.60-0.83, P < 0.05) as compared with LC/LA volume surgeons. There was no significant difference in rates of anastomotic leak, nonroutine discharges or readmission among all four groups. CONCLUSIONS: The best early postoperative surgical outcomes are achieved in centers where there are high cumulative and high annual volume surgeons caring for these patients. This suggests the need for specialized designation of rectal cancer centers to support ongoing regionalization of care.

Dynamic Article: Full-Thickness Excision for Benign Colon Polyps Using Combined Endoscopic Laparoscopic Surgery.

BACKGROUND: Benign colon polyps are commonly encountered but may not always be amenable to endoscopic excision because of their size, shape, location, or scarring from previous attempts. The addition of laparoscopy allows a greater degree of bowel manipulation, but the current technique is still limited when encountering a polyp with inadequate lifting attributed to polyp morphology or scarring. We describe an extension to the existing combined endoscopic laparoscopic surgery technique using a full-thickness approach to increase polyp maneuverability and local excision of difficult but benign polyps. OBJECTIVE: The purpose of this study was to report the technical details and preliminary results of a new approach for full-thickness excision of difficult colon polyps, combined endoscopic laparoscopic surgery full-thickness excision. DESIGN: This study is a retrospective review of our experience from December 2013 to May 2015. SETTINGS: The study was conducted at a single academic institution. PATIENTS: All of the patients had previous incomplete colonoscopic polypectomy performed at other institutions. Patients were selected for our technique if the polyp had a benign appearance but was unable to be resected by traditional endoscopic or combined endoscopic laparoscopic surgery methods because of polyp morphology or scarring from previous biopsies. MAIN OUTCOME MEASURES: The safety and feasibility of this procedure were measured. RESULTS: Three patients underwent combined endoscopic laparoscopic surgery-full-thickness excision for difficult colon polyps. There were no intraoperative or postoperative complications. The length of stay was 1 day for all of the patients. All 3 of the patients had benign final pathology. LIMITATIONS: This study was limited by the small number of patients in a single institution. CONCLUSIONS: Full-thickness excision for benign colon polyps using combined endoscopic laparoscopic surgery is safe and feasible. Using this technique, difficult polyps not amenable to traditional endoscopic approaches can be removed and colectomy may be avoided.

Surgical oncology outcomes in the aging US population.

BACKGROUND: As the population ages, an increasing number of older patients are undergoing major surgery. We examined the impact of advanced age on outcomes following major gastrointestinal cancer surgery in an era of improved surgical outcomes. MATERIALS AND METHODS: This was a population-based, retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated patients undergoing major abdominal gastrointestinal cancer surgery from 2005-2012. Multivariable logistic regression was performed to determine the independent effect of advanced age on outcomes. Our primary outcome was 30-d mortality, and our secondary outcomes were 30-d major postoperative adverse events, discharge disposition, length of stay, reoperation, and readmission. RESULTS: Elderly (≥65 y) patients were twice as likely to have multiple comorbidities as those <65 y but prevalence of comorbidities was similar across all older age groups. Mortality increased with age across all procedures (P < 0.05). The risk of advanced age on mortality was highest in hepatectomy (odds ratio = 5.17, 95% confidence interval = 2.19-12.20) and that for major postoperative adverse events was highest in proctectomy (odds ratio = 2.32, 95% confidence interval = 1.53-3.52). Patients were more likely to be discharged to an institutional care facility as age increased across all procedures (P < 0.01). CONCLUSIONS: Despite being highly selected for surgery, elderly patients undergoing major gastrointestinal cancer surgery have substantially worse postoperative outcomes than younger patients (<65 y). The risk of age on postoperative outcomes was present across all operations but had its highest association with liver and rectal cancer resections.

Driving Surgical Quality Using Operative Video.

Recent evidence suggests surgical quality may be demonstrated and evaluated using video capture during surgery. Operative video documentation may also aid in quality improvement initiatives. We discuss how operative video has the potential to help improve patient outcomes and increase professional accountability, patient safety, and surgical quality.

Adenocarcinoma of the ileal pouch mucosa: case report and literature review.

PURPOSE: Cancers developing near the site of the ileoanal pouch anastomosis (IPAA) have been reported, but uncommonly in the ileal pouch mucosa itself. We present a recently encountered case of ileal pouch cancer and review the literature to examine the prevalence, risk factors, and natural history of ileal pouch adenocarcinoma as well as pouch surveillance. METHODS: A chart review of the case from our institution was conducted, and a PubMed search was undertaken for articles describing adenocarcinoma arising from the ileal pouch mucosa. RESULTS: Twenty articles containing 26 cases were reviewed in addition to our described case. More than half were reported in the last decade. Only three cases were definitively stage 1. All seven patients who underwent regular surveillance were diagnosed with stage 1 or 2 disease. Seventeen patients had neoplasia in their original proctocolectomy specimen and six did not. The mean time from pouch creation to adenocarcinoma was 8.9 years. CONCLUSIONS: The risk of developing ileal pouch mucosa adenocarcinoma appears low. However, increasing reports of these cancers are concerning as most patients present with advanced disease after many years. Patients with a previous history of dysplasia/cancer may be at increased risk. We believe surveillance after IPAA should include the anal transition zone and the ileal pouch mucosa. The establishment of expert consensus guidelines on pouch surveillance should be considered in the near future.

Centralization of pancreatoduodenectomy a decade later: Impact of the volume-outcome relationship.

BACKGROUND: The hospital volume-outcome relationship for complex procedures has led to the suggestion that care should be centralized. This study was performed to investigate whether centralization is occurring for pancreatoduodenectomy (PD) and to examine its effect on short-term postoperative outcomes. METHODS: We queried the New York State Statewide Planning and Research Cooperative System database (n = 6,185, 2002-2011) and the California and Florida State Inpatient Databases (n = 6,766 and 4,810, respectively, 2002-2011) for PD. Hospitals were divided into low (≤10), medium (11-25), high (25-60), and very high (≥61) groups depending on annual volume. Hierarchical logistic modeling accounted for patient clustering within hospitals. RESULTS: A migration of cases from low-volume to medium, high, and very high-volume (MHVH) hospitals occurred in these 3 states (P < .01). There was an increase in the number of MHVH hospitals and a decrease in the number of low-volume hospitals performing PD across all states over time, with a large number of hospitals ceasing to perform PD cases entirely. Comorbidities such as congestive heart failure and diabetes were more prevalent in low-volume hospitals. After we adjusted for all predictors, MHVH hospitals had less rates of mortality and morbidity and shorter durations of stay than low-volume hospitals (P < .05); 30-day readmission rates were similar across all volume groups. CONCLUSION: Centralization of PD is occurring in these 3 states and probably across the nation. After PD, MHVH hospitals had statistically better outcomes (mortality, morbidity, and duration of stay) than low-volume hospitals. Readmission rates were not affected by volume.

Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study.

BACKGROUND: High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy. MATERIALS AND METHODS: A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons. RESULTS: Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels. CONCLUSIONS: Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.

Retinal vein occlusion and traditional risk factors for atherosclerosis.

OBJECTIVE: To determine whether retinal vein occlusion (RVO) is related to systemic hypertension, diabetes mellitus, and hyperlipidemia. METHODS: We systematically retrieved all studies published between January 1985 and July 2007 that compared cases with any form of RVO, including central and branch RVO, with controls. We generated pooled odds ratios (ORs) and estimates of the population-attributable risk percentages for systemic hypertension, diabetes mellitus, and hyperlipidemia. RESULTS: Of 21 studies, including 2916 cases and 28 646 controls, both hypertension (OR, 3.5; 95% confidence interval [CI], 2.5-5.1) and hyperlipidemia (OR, 2.5; 95% CI, 1.7-3.7) were significantly associated with any form of RVO; the association was less pronounced for diabetes mellitus (OR, 1.5; 95% CI, 1.1-2.0). Similar results were found in cases with central RVO and branch RVO. The percentage of cases with any form of RVO attributed to hypertension was 47.9% (95% CI, 31.2%-63.1%), to diabetes mellitus was 4.9% (95% CI, 0.8%-11.5%), and to hyperlipidemia was 20.1% (95% CI, 5.9%-43.8%). CONCLUSIONS: Hypertension and hyperlipidemia are common risk factors for RVO in adults, and diabetes mellitus is less so. It remains to be determined whether lowering blood pressure and/or serum lipid levels can improve visual acuity or the complications of RVO.