Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality

IMPORTANCE

Programs that analyze and report rates of surgical complications are an increasing focus of quality improvement efforts. The most comprehensive tool currently used for outcomes monitoring in the United States is the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP).

OBJECTIVE

To compare surgical outcomes experienced by patients treated at hospitals that did vs did not participate in the NSQIP.

DESIGN, SETTING, AND PARTICIPANTS

Data from the University HealthSystem Consortium from January 2009 to July 2013 were used to identify elective hospitalizations representing a broad spectrum of elective general/vascular operations in the United States. Data on hospital participation in the NSQIP were obtained through review of semiannual reports published by the ACS. Hospitalizations at any hospital that discontinued or initiated participation in the NSQIP during the study period were excluded after the date on which that hospital's status changed. A difference-in-differences approach was used to model the association between hospital-based participation in NSQIP and changes in rates of postoperative outcomes over time.

EXPOSURE

Hospital participation in the NSQIP.

MAIN OUTCOMES AND MEASURES

Risk-adjusted rates of any complications, serious complications, and mortality during a hospitalization for elective general/vascular surgery.

RESULTS

The cohort included 345,357 hospitalizations occurring in 113 different academic hospitals; 172,882 (50.1%) hospitalizations were in NSQIP hospitals. Hospitalized patients were predominantly female (61.5%), with a mean age of 55.7 years. The types of procedures performed most commonly in the analyzed hospitalizations were hernia repairs (15.7%), bariatric (10.5%), mastectomy (9.7%), and cholecystectomy (9.0%). After accounting for patient risk, procedure type, underlying hospital performance, and temporal trends, the difference-in-differences model demonstrated no statistically significant differences over time between NSQIP and non-NSQIP hospitals in terms of likelihood of complications (adjusted odds ratio, 1.00; 95% CI, 0.97-1.03), serious complications (adjusted odds ratio, 0.98; 95% CI, 0.94-1.03), or mortality (adjusted odds ratio, 1.04; 95% CI, 0.94-1.14).

CONCLUSIONS AND RELEVANCE

No association was found between hospital-based participation in the NSQIP and improvements in postoperative outcomes over time within a large cohort of patients undergoing elective general/vascular operations at academic hospitals in the United States. These findings suggest that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement.

Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies

BACKGROUND

Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients.

DESIGN

We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression.

RESULTS

From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4).

CONCLUSIONS

Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.

Performance measurement in surgery through the National Quality Forum

BACKGROUND

Performance measurement has become central to surgical practice. We systematically reviewed all endorsed performance measures from the National Quality Forum, the national clearing house for performance measures in health care, to identify measures relevant to surgical practice and describe measure stewardship, measure types, and identify gaps in measurement.

STUDY DESIGN

Performance measures current to June 2014 were categorized by denominator statement as either assessing surgical practice in specific or as part of a mixed medical and surgical population. Measures were further classified by surgical specialty, Donabedian measure type, patients, disease and events targeted, reporting eligibility, and measure stewards.

RESULTS

Of 637 measures, 123 measures assessed surgical performance in specific and 123 assessed surgical performance in aggregate. Physician societies (51 of 123, 41.5%) were more common than government agencies (32 of 123, 26.0%) among measure stewards for surgical measures, in particular, the Society for Thoracic Surgery (n = 32). Outcomes measures rather than process measures were common among surgical measures (62 of 123, 50.4%) compared with aggregate medical/surgical measures (46 of 123, 37.4%). Among outcomes measures, death alone was the most commonly specified outcome (24 of 62, 38.7%). Only 1 surgical measure addressed patient-centered care and only 1 measure addressed hospital readmission. We found 7 current surgical measures eligible for value-based purchasing.

CONCLUSIONS

Surgical society stewards and outcomes measure types, particularly for cardiac surgery, were well represented in the National Quality Forum. Measures addressing patient-centered outcomes and the value of surgical decision-making were not well represented and may be suitable targets for measure innovation.

Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery

BACKGROUND

The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery.

METHODS

A database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management.

RESULTS

Five hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82.4 to 99.3 per cent. Median length of hospital stay was 3 (i.q.r. 2-5) days, with 25.9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2-4) days if compliant and 3 (3-5) days if not (P < 0.001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1.97, 95 per cent confidence interval 1.29 to 3.03; P = 0.002), full compliance (OR 2.36, 1.42 to 3.90; P < 0.001) and high surgeon volume (more than 100 cases per year) (OR 1.50, 1.19 to 1.89; P < 0.001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8.1 versus 19.6 per cent; P = 0.001). Median oral opiate intake was 37.5 (i.q.r. 0-105) mg in 48 h, with 26.2 per cent of patients receiving no opiates.

CONCLUSION

Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.

Timing of complications and length of stay after rectal cancer surgery

BACKGROUND

Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway.

STUDY DESIGN

This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery.

RESULTS

A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73-0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09-3.78; p < 0.001) after adjusting for comorbidities in a competing risk model.

CONCLUSIONS

Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities.

How to improve the performance of intraoperative risk models: an example with vital signs using the surgical apgar score

BACKGROUND

Computerized reviews of patient data promise to improve patient care through early and accurate identification of at-risk and well patients. The significance of sampling strategy for patient vital signs data is not known. In the instance of the surgical Apgar score (SAS), we hypothesized that larger sampling intervals would improve the specificity and overall predictive ability of this tool.

METHODS

We used electronic intraoperative data from general and vascular surgical patients in a single-institution registry of the American College of Surgeons National Surgical Quality Improvement Program. The SAS, consisting of lowest heart rate, lowest mean arterial blood pressure, and estimated blood loss between incision and skin closure, was calculated using 5 methods: instantaneously and using intervals of of 5 and 10 minutes with and without interval overlap. Major complications including death were assessed at 30 days postoperatively.

RESULTS

Among 3000 patients, 272 (9.1%) experienced major complications or death. As the sampling interval increased from instantaneous (shortest) to 10 minutes without overlap (largest), the sensitivity, positive predictive value, and negative predictive value did not change significantly, but significant improvements were noted for specificity (79.5% to 82.9% across methods, P for trend <0.001) and accuracy (76.0% to 79.3% across methods, P for trend <0.01). In multivariate modeling, the predictive utility of the SAS as measured by the c-statistic nearly increased from Δc = +0.012 (P = 0.038) to Δc = +0.021 (P < 0.002) between the shortest and largest sampling intervals, respectively. Compared with a preoperative risk model, the net reclassification improvement and integrated discrimination improvement for the shortest versus largest sampling intervals of the SAS were net reclassification improvement 0.01 (P = 0.8) vs 0.06 (P = 0.02), and for integrated discrimination improvement, they were 0.008 (P < 0.01) vs 0.015 (P < 0.001).

CONCLUSIONS

When vital signs data are recorded in compliance with American Society of Anesthesiologists' standards, the sampling strategy for vital signs significantly influences performance of the SAS. Computerized reviews of patient data are subject to the choice of sampling methods for vital signs and may have the potential to be optimized for safe, efficient patient care.

Assessment of prophylactic antibiotic use in patients with surgical site infections

BACKGROUND

Surgical site infections (SSIs) are the leading cause of hospital-acquired infections and are associated with substantial health care costs, with increased morbidity and death. The Surgical Care Improvement Project (SCIP) contains standards that are nationally reported with the aim of improving patient outcomes after surgery. Our institution's standards for antimicrobial prophylaxis in the perioperative period are more stringent than these measures and may be considered "beyond SCIP." The 4 elements of appropriate antimicrobial prophylaxis are timing, antibiotic selection, dosing, and intraoperative redosing.

OBJECTIVE

To quantify antimicrobial SSI prophylaxis compliance in accordance with institutional standards and to identify potential opportunities for improvement.

METHODS

Patients aged 18 years or older were included if they had an SSI between January 1, 2009, and June 30, 2010, according to the database maintained prospectively by the Infection Prevention and Control Unit. Adherence to our institution's practice standards was assessed through analysis of antibiotics administered-timing in relation to the incision, closure, and tourniquet inflation times for the procedure and antibiotic selection, dose, and redosing.

RESULTS

Overall noncompliance with all 4 elements of antimicrobial prophylaxis was 75.4% among the 760 cases. Repeat dosing had the greatest noncompliance (45.1%); antibiotic selection had the lowest incidence of noncompliance (10.8%).

CONCLUSIONS

Noncompliance existed in each element of antimicrobial SSI prophylaxis, with antibiotic redosing leading in noncompliance. With the implementation of tools to assist the surgical team in following institutional standards, noncompliance will likely decline and additional research opportunities will exist.

Risk of neoplastic change in ileal pouches in familial adenomatous polyposis

INTRODUCTION

Neoplastic change in ileal reservoirs after proctocolectomy has been reported in patients with familial adenomatous polyposis. We aim to determine the incidence and progression of neoplastic change in the ileal pouch of familial adenomatous polyposis patients at our institution.

METHODS

A retrospective review of all patients who underwent proctocolectomy for familial adenomatous polyposis with construction of an ileal pouch from 1972 to 2007 was performed. Data and status at follow-up were retrieved from the Mayo Clinic Colorectal Surgery Pouch database.

RESULTS

One hundred seventeen patients were identified with a median age of 26, 52 were male. Ileal reservoirs included J-pouch (a = 104), Kock pouch (n = 9), S-pouch (n = 3), and W-pouch (n = 1). Median follow-up was 125 months. Polyps were biopsied in 33 patients: non-dysplastic polyps (n = 2), low-grade dysplasia (n = 30), and adenocarcinoma (n = 1). No patients had high-grade dysplasia. Median time to development of dysplasia was 149 months. Adenocarcinoma developed in one patient after 284 months. Risk of dysplasia at 10, 20, and 25 years was 17, 45, and 69%, respectively.

CONCLUSION

Though there is a high incidence of low-grade dysplasia in the ileal reservoir in familial adenomatous polyposis patients, high-grade dysplasia and cancer occur rarely. Patients with low-grade dysplasia may still necessitate regular follow-up.

Locally recurrent colorectal cancer and hepatic metastases: Safety, feasibility, and outcomes after concomitant resection

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Background: The most effective management of locally recurrent colorectal cancer (CRC) is resection. This is also true for hepatic metastases (HM). Data remains limited, however, regarding concomitant resection of recurrent CRC and HM. The aims of this study were to determine the feasibility, safety and outcomes in terms of disease-free survival (DFS) and overall survival (OS) in patients undergoing concomitant resection of recurrent CRC with HM. Methods: All patients who underwent resection of recurrent CRC from 1/1995 to 1/2007 at Mayo Clinic, Rochester were reviewed (n=406). The study group consisted of patients who underwentconcomitant resection of locally recurrent CRC and hepatic resection for metastatic CRC (n= 45). Kaplan-Meier Survival was used to estimate DFS and OS. Results: The study group consisted of 27 men and 18 women. The median age was 59 years. Surgical management involved pelvic dissection in 43 patients and ileotransverse colectomy in two. 17 patients required resection of contiguous organs. 24 patients received intra-operative radiation. 34 patients underwent multiple hepatic wedge resections, 6 patients segmentectomy, 3 left hepatectomy, and 2 right hepatectomy. There was no perioperative mortality. Morbidity was 37%, 2 patients required re-operation. The 1, 3, and 5 year DFS was 72.2, 42.3, and 18.5%, respectively. The 1, 3, and 5 year OS was 87.7, 47.6, and 36.2%, respectively. Conclusions: Synchronous resection of locally recurrent CRC and HM is safe and feasible; morbidity is reasonable and mortality zero. DFS and OS in this patient population appear comparable to that of patients undergoing separate, staged resections.

Diagnoses influence surgical site infections (SSI) in colorectal surgery: a must consideration for SSI reporting programs?

BACKGROUND

Colorectal surgery is associated with high rates of surgical site infection (SSI). The National Surgery Quality Improvement Program is a validated, risk-adjusted quality-improvement program for surgical patients. Patient stratification and risk adjustment are associated with Current Procedural Terminology codes and primary disease diagnosis is not considered. Our aim was to determine the association between disease diagnosis and SSI rates.

METHODS

Data from all 2009 National Surgery Quality Improvement Program institutions were analyzed. ICD-9 codes were used to differentiate patients into cancer (colon or rectal), ulcerative colitis, regional enteritis, diverticular disease, and others. Diagnosis-specific SSI rates were compared with benign neoplasm, which had the lowest rate (8.9%). Logistic regression was performed adjusting for age, body mass index, American Society of Anesthesiologists classification, wound type, and relative value unit.

RESULTS

There were 24,673 colorectal procedures, with 1,956 superficial incisional (SSSI), 398 deep incisional (DSSI), and 1,096 organ/space (O/SSSI) infections. Odds ratio (OR) and 95% confidence intervals compared with benign neoplasm diagnosis were computed after adjustment for each diagnosis category. In rectal cancer patients, significantly more SSSI (OR = 1.6; 95% CI, 1.3-2.1; p < 0.0001), DSSI (OR = 2.1; 95% CI, 1.3-3.7; p = 0.006), and O/SSSI (OR = 2.2; 95% CI, 1.6-3.0; p < 0.0001) developed. In diverticular patients, more SSSI (OR = 1.6; 95% CI, 1.3-2.0; p < 0.0001), but not DSSI or O/SSSI, developed. In ulcerative colitis patients, more DSSI (OR = 2.4; 95% CI, 1.2-4.9; p = 0.01), O/SSSI (OR = 2.1; 95% CI, 1.4-3.1; p = 0.0004), but fewer SSSIs, developed.

CONCLUSIONS

We found that SSI type is associated with the underlying disease diagnosis. To facilitate colorectal SSI-reduction efforts, the disease process must be considered to design appropriate interventions. In addition, institutional comparisons based on aggregate or stratified SSI rates can be misleading if the colorectal disease mix is not considered.

Loop ileostomy reversal after colon and rectal surgery: a single institutional 5-year experience in 944 patients

BACKGROUND

Diverting loop ileostomy is used to mitigate the sequelae of anastomotic dehiscence.

OBJECTIVE

To report the rate of complications after ileostomy reversal using standardized definitions to aid physicians who are deciding whether to divert anastomoses.

METHODS

Patients who underwent diverting loop ileostomy closure from January 1, 2005, through February 28, 2010, were identified using a prospective database. Perioperative variables and 30-day outcomes were reviewed. Complications were graded according to the Clavien-Dindo Classification, in which grade III, IV, or V represents major complications. Univariate analysis assessed the relationship between operative variables and surgical outcomes.

RESULTS

A total of 944 patients underwent reversal: 43.1% were women, the mean age was 47.2 years, the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 25.7, and 18.5% were American Society of Anesthesiologists class III or IV. Indications for the initial operation were ulcerative colitis (49.5%), rectal cancer (27.5%), diverticular disease (6.8%), and other (16.1%). Anastomotic technique for reversal was sutured fold-over in 466 patients (49.4%), stapled in 315 (33.4%), and handsewn end to end in 163 (17.3%). After reversal, the mean time to first bowel movement, tolerance of soft diet, and discharge from hospital was 2.6, 3.7, and 5.2 days, respectively. Handsewn cases had longer operative times and longer times to bowel movement, soft diet, and discharge. Overall, complications occurred in 203 patients (21.5%), including 45 patients (4.8%) who experienced a major complication; there were no deaths within 30 days.

CONCLUSION

Ileostomy closure is associated with a low rate of major grade III and IV complications and should be reserved for patients who have a predicted postoperative major complication rate of 5% or more without diversion.

Technical proficiency in hand-assisted laparoscopic colon and rectal surgery: determining how many cases are required to achieve mastery

OBJECTIVE

To determine how many cases are required to achieve technical proficiency for hand-assisted laparoscopic surgery (HALS).

DESIGN

Retrospective study.

SETTING

Tertiary care hospital.

PATIENTS

Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases.

INTERVENTIONS

Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the "learning period" and "skilled period."

MAIN OUTCOME MEASURES

Operative time; short-term outcomes.

RESULTS

The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P < .001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P = .003); left colectomy, 63 minutes (P = .006); sigmoid colectomy, 63 minutes (P < .001); anterior resection, 70 minutes (P < .001); coloanal anastomosis, 52 minutes (P = .003); subtotal colectomy, 75 minutes (P < .001); and total proctocolectomy with ileal reservoir, 80 minutes (P < .001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P < .05) lower during the skilled period.

CONCLUSIONS

For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons.

Outcomes following surgery without radiotherapy for rectal cancer

BACKGROUND

This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy.

METHODS

This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board.

RESULTS

Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis.

CONCLUSION

Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit.

Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months

BACKGROUND

Retained surgical items (RSIs), most commonly sponges, are infrequent. Yet despite sponge-counting standards, failure to maintain an accurate count is a common error. To improve counting performance, technology solutions have been developed. A data-matrix-coded sponge (DMS) system was evaluated and implemented in a high-volume academic surgical practice at Mayo Clinic Rochester (MCR). The primary end point was prevention of sponge RSIs after 18 months.

METHODS

Two trials were conducted before implementation. A randomized-controlled trial assessed the system's function, efficiency, and ergonomics. The second, larger trial was conducted to validate the prior findings and test product improvements. After the trials, the system was implemented in all 128 operating/procedure rooms across the MCR campus on February 2, 2009. The institutionwide implementation was intended to avoid the possibility of having standard unmarked sponges and DMSs in the operating room suite concurrently.

RESULTS

Before implementation, a retained sponge occurred on average every 64 days. Between February 2009 and July 2010, 87,404 procedures were performed, and 1,862,373 DMSs were used without an RSI (p < .001). After four cases, the average time to count a DMS decreased from 11 to 4 seconds. Total sponge counting time/operation increased without any increase in overall operative time.

CONCLUSIONS

After 18 months, a DMS system eliminated sponge RSIs from a high-volume surgical practice. The DMS system caused no work-flow disruption or increases in case duration. Staff satisfaction was acceptable, with a high degree of trust in the system. The DMS system is a reliable and cost-effective technology that improves patient safety.

Management and outcomes of primary coloduodenal fistulas

PURPOSE

Primary coloduodenal fistula (CDF) is a rare entity. We review our experience with the management and outcomes of CDF.

METHODS

This is a retrospective review from 1975 to 2005 of patients with primary CDF. Patients were followed through clinic visits and mail correspondence with a mean (±SE) follow-up of 56 ± 14 months.

RESULTS

Twenty-two patients were diagnosed at a mean age of 54 ± 3 years with primary CDF: benign (n = 14) or malignant (n = 8). Benign CDF were due to Crohn's disease (n = 9) or peptic ulcer disease (n = 5); malignant CDF was primarily due to colon cancer (n = 7) plus 1 patient with lymphoma. Indications for operative intervention included intractable symptoms (n = 15), gastrointestinal bleeding (n = 14), and to rule out malignancy (n = 8). Complete resection of malignant CDF with negative margins was achieved in half of patients after en bloc resection. Palliative bypass was performed in those patients with unresectable disease. Thirteen patients with benign CDF had resection of the fistula-2 of these patients required a duodenal bypass. There were no perioperative deaths, and the morbidity rate was 38%. Median survival for patients with malignant CDF was 20 months (range 1-150 months). Two patients with malignant CDF had >5-year survival. All patients with benign CDF who underwent fistula resection had resolution of fistula-related symptoms with one recurrence.

CONCLUSION

Benign CDF is amenable to operative therapy with resolution of symptoms and a low recurrence rate. Complete resection of malignant CDF can impart survival benefit.

Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery

BACKGROUND

Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations.

METHODS

An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared.

RESULTS

Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2-3) versus 3 (3-5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1-2) versus 2 (2-3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days).

CONCLUSION

ERP decreased the length of hospital stay after minimally invasive colorectal surgery.

Utility and short-term outcomes of hand-assisted laparoscopic colorectal surgery: a single-institution experience in 1103 patients

BACKGROUND

Despite its introduction in 1991, laparoscopic colectomy is performed in <10% of United States patients requiring colectomy. Laparoscopic colectomy is avoided principally because of its technical difficulty, steep learning curve, and increased operative times. Hand-assisted laparoscopic colectomy is an alternative technique that addresses these problems while preserving the short-term benefits of laparoscopic colectomy.

OBJECTIVE

To describe the utility and short-term outcomes, we evaluated 1103 patients who underwent hand-assisted laparoscopic colorectal resections over a 5-year period.

DESIGN

This study was a retrospective analysis of prospectively collected data.

SETTINGS

The setting was a single tertiary care institution.

PATIENTS

A total of 1103 consecutive hand-assisted laparoscopic colorectal resections from 2004 to 2009 were identified using a prospectively maintained database.

MAIN OUTCOME MEASURES

Demographics, perioperative variables, and 30-day outcomes were reported. Data are presented as frequency (proportion) or median (interquartile range).

RESULTS

A total of 1103 hand-assisted laparoscopic colorectal resections were documented. Median age of patients was 55 years; 47% were women, and median body mass index was 26.5 (range, 23-34) kg/m. Diagnoses included inflammatory bowel disease (35%), colorectal cancer (31%), diverticular disease (23%), and "other" (11%). Forty-two percent of patients had prior abdominal surgery. Segmental colectomies were performed in 533 (48%) patients, proctocolectomy with ileal pouch-anal anastomosis in 229 (21%), proctocolectomy with end ileostomy in 114 (10%), and "other" in 227 (21%). The conversion rate was 9%. Overall median operative time was 201 (range, 145-269) minutes, and the median postoperative length of stay was 5 (range, 4-7) days. Postoperative complications occurred in 27% and readmissions in 7%; mortality was 0.3%.

LIMITATIONS

This was a single institutional retrospective study.

CONCLUSIONS

Hand-assisted laparoscopic colorectal resection can be performed for numerous indications. It preserves nearly all the benefits of laparoscopic colectomy reported in the literature. With experience, it is associated with significantly reduced operative times. Wider adoption of hand-assisted laparoscopic colorectal surgery would increase the number of patients benefiting from minimal access colorectal surgery.