Historical Perspectives on Colorectal Trauma Management.

The authors discuss the history and evolution of management of traumatic wounds to the colon and rectum, summarizing early management parallel with the history of armed conflict followed by the increase in research and management interest by civilian centers in the post-Vietnam era. They explore the strong opinions of the early thought-leaders such as DeBakey and Ogilvie, detailing factors that may have impacted their views. The current literature on optimal management of both colon and rectal trauma is reviewed, including the contentious debate over which patients may benefit from diversion. Current organ injury staging and clinical practice guidelines are also reviewed, as well as lessons learned by the U.S. military in recent conflicts in Iraq and Afghanistan. Understanding of the evolution of colon and rectal trauma management, as well as the current literature, will help surgeons in their decision-making and management of these challenging injuries.

Acute health care resource utilization for ileostomy patients is higher than expected.

BACKGROUND: Patients requiring an ileostomy following colorectal surgery are at risk for increased health-care utilization after discharge. Prior studies evaluating postoperative ileostomy care may underestimate health-care utilization by reporting only "same-institution" readmission rates. OBJECTIVE: The aim of this study was to determine the rates of health-care utilization of new ostomates within 30 days of discharge in a multicenter environment. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at acute-care, community hospitals in California, Florida, Nebraska, and New York. PATIENTS: Adult patients who underwent colorectal surgery with primary anastomosis, colostomy, or ileostomy between July 2009 and September 2010 were identified. MAIN OUTCOME MEASURES: The primary outcome measured was hospital-based acute care, defined as hospital readmission or emergency department visit, at any hospital within 30 days of surgery. Multivariate regression models were used to compare the outcomes across groups. RESULTS: Overall, 75,136 patients underwent colectomy with most receiving a primary anastomosis (79.3%), whereas colostomies were created in 12.8% and ileostomies were created in 8.0%. Diagnoses of colorectal cancer (36.1%) or diverticular disease (22.0%) were most common. Patients with a colostomy (18.8%; adjusted odds ratio [AOR], 1.23 [95% CI, 1.17-1.30]) or ileostomy (36.1%; AOR, 2.28 [95% CI 2.15-2.42]) were significantly more likely than patients with a primary anastomosis (16.2%) to have a hospital-based acute-care encounter within 30 days of discharge. Among patients undergoing ileostomy, postoperative infection, renal failure, and dehydration were the most common diagnoses for hospital-based acute-care events. Overall, 20% of these encounters occurred at hospitals other than where the index surgery occurred. LIMITATIONS: Coding accuracy, the inability to capture events occurring in physician offices, and the retrospective study design were limitations of the study. CONCLUSIONS: Patients undergoing colorectal surgery with an ileostomy return to the hospital after discharge twice as frequently as those with a primary anastomosis or colostomy, often to hospitals other than the primary institution. As postdischarge health-care utilization becomes a measured quality metric, it is increasingly important to help these patients to safely transition to home.

Outcomes and costs associated with robotic colectomy in the minimally invasive era.

BACKGROUND: Robotic-assisted surgery has become increasingly common; however, it is unclear if its use for colectomy improves in-hospital outcomes compared with the laparoscopic approach. OBJECTIVE: The aim of the study is to compare in-hospital outcomes and costs between patients undergoing robotic or laparoscopic colectomy. DESIGN: This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS: All adult patients who underwent an elective robotic or laparoscopic colectomy in hospitals performing both procedures (N = 2583 representing an estimated 12,732 procedures) were included. MAIN OUTCOME MEASURES: Outcomes included intraoperative and postoperative complications, length of stay, and direct costs of care. Regression models were used to compare these outcomes between procedural approaches while controlling for baseline differences in patient characteristics. RESULTS: Overall, 6.1% of patients underwent a robotic procedure. Factors associated with robotic-assisted colectomy included younger age, benign diagnoses, and treatment at a lower-volume center. Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35-2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54-1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different. LIMITATIONS: A limitation of this study is the potential miscoding of robotic cases in administrative data. CONCLUSIONS: Robotic-assisted colectomy significantly increases the costs of care without providing clear reductions in overall morbidity or length of stay. As the use of robotic technology in colon surgery continues to evolve, critical appraisal of the benefits offered in comparison with the resources consumed is required.

Standardized pretreatment breast MRI--accuracy and influence on mastectomy decisions.

BACKGROUND AND OBJECTIVES: Routine pretreatment breast magnetic resonance imaging in newly diagnosed cancer patients remains controversial. We assess MRI accuracy and influence on mastectomy decisions after institution of standardized pretreatment MRI. METHODS: A prospectively collected database of 74 consecutive new invasive breast cancer patients with pretreatment breast MRI was reviewed for treatment choice, radiologic, and pathologic results. Thirty-eight of 72 patients with available surgical records underwent mastectomy. Mastectomy preoperative and operative electronic records were reviewed for treatment decision analysis. RESULTS: Seventeen of 72 (23.6%) invasive breast cancer patients were likely influenced to undergo mastectomy by new information from MRI. MRI reported that the multifocal/multicentric (MF/MC) rate was 20 of 72 (27.8%) versus 19 of 72 (26.4%) by surgical pathology. MRI sensitivity for MF/MC disease was 89.5% versus 11.8% for mammography. MRI specificity was 84.2%. All three false positives declined recommended preoperative biopsies. MRI MF/MC diagnosis highly correlated with pathology results, P < 0.001. CONCLUSIONS: Increased mastectomy rate from 29 to 52.8% after standardization of pre-treatment breast MRI for invasive cancer is largely due to MRI findings of increased extent of disease. These MRI findings correlate well with pathologic findings and appear to justify the performance of mastectomies in these patients.

Sterile intra-abdominal fluid collection associated with seprafilm use.

Postoperative abdominal adhesions are a significant cause of morbidity and expenditure of healthcare resources. As a result, numerous substances have been studied in an effort to reduce the incidence of adhesive disease. Seprafilm, a hyaluronate-based bioresorbable membrane, has been the subject of considerable research and has been found to be both safe and effective in reducing postoperative adhesions. We report three cases of the development of sterile abdominal fluid collection after the use of Seprafilm in colorectal surgery.

A variation in the value of colectomy for cancer across hospitals: mortality, readmissions, and costs.

INTRODUCTION: Although hospital variation in costs and outcomes has been described for patients undergoing operation, the relationship between them is unknown. The purpose of this study was to evaluate this relationship among patients undergoing colon resection for cancer and identify characteristics of "high-quality, low-cost" hospitals. METHODS: We identified adult patients who underwent colon resection for cancer in California, Florida, and New York from 2009 to 2010. We estimated hospital-level, risk-standardized 30-day hospital costs, in-hospital mortality rates, and 30-day readmission rates by using hierarchical generalized linear models. Costs were compared between hospitals identified as low, average, and high performers. RESULTS: The final sample included 14,790 patients discharged from 389 hospitals. After adjusting for case mix, variation was noted in risk-standardized costs (median = $26,169, inter-quartile range [IQR] = $6,559), in-hospital mortality (median = 1.8%, IQR = 2.3%), and 30-day readmission (12.2%, IQR = 0.7%) rates. Minimal correlation was noted between a hospital's costs and outcomes, with similar costs noted across hospital performance groups (low = $25,994 vs average = $26,998 vs high = $25,794, P = .19). High-quality, low-cost hospitals treated a greater percentage of Medicare beneficiaries, approached fewer cases laparoscopically, and trended toward greater volume. CONCLUSION: Hospital costs are not correlated with outcomes in this population. More work is needed to identify means of providing high-quality care at lesser costs.

Combat readiness for the modern military surgeon: data from a decade of combat operations.

OBJECTIVE: Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS: A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS: Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION: These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.

Current US military operations and implications for military surgical training.

BACKGROUND: Since 2001, US military surgeons have deployed frequently, with many surgeons deploying within 1 year of graduating residency. The purpose of this study was to evaluate readiness of recent graduates to manage combat-related injuries and to make recommendations for improvements in training military surgeons. STUDY DESIGN: We reviewed casualties treated at the 31st Combat Support Hospital in Baghdad from December 2003 to November 2004. We identified 3,426 wounded patients; of these, 2,648 (77.3%) required an operative procedure. There were 2,788 patients (81.4%) who sustained penetrating injuries. The most common procedures performed were debridement of wounds (39%), skeletal fixation (14.7%), and exploratory laparotomy (11.4%). Common procedures were compared with 15 case logs from the ACGME database for our institution from 2005 to 2009. RESULTS: Graduating residents averaged 973 cases during residency (range 867 to 1,293, median 921). This included experience with most procedures encountered except nephrectomy (1.5 procedures per resident [PPR]), craniotomy (1.1 PPRs), inferior vena cava injury (1.1 PPRs), bladder repair (0.87 PPR), and duodenal injury (0.6 PPR). Residents had minimal experience with skeletal fixation and external genital trauma. CONCLUSIONS: Recent surgical residency graduates are prepared for deployment in support of US military operations for the majority of injuries encountered. However, familiarization with procedures that fall outside the traditional general surgical curriculum would improve their ability to treat these injuries. To enhance experience with rare injuries, cadaver studies and animal models may serve as training tools before deployment.