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Ferrari D, Violante T, Gomaa IA, Cima RR. Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach. Updates Surg 2024:10.1007/s13304-024-01813-7. [PMID: 38573448 DOI: 10.1007/s13304-024-01813-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.
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Affiliation(s)
- Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Alma Mater Studiorum, School of General Surgery, Università di Bologna, Bologna, Italy
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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McKenna NP, Bews KA, Behm KT, Mathis KL, Cima RR, Habermann EB. Timing and Location of Venous Thromboembolisms After Surgery for Inflammatory Bowel Disease. J Surg Res 2024; 296:563-570. [PMID: 38340490 DOI: 10.1016/j.jss.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- Nicholas P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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3
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Violante T, Ferrari D, Gomaa IA, Rumer KK, D'Angelo ALD, Behm KT, Shawki SF, Perry WRG, Kelley SR, Mathis KL, Dozois EJ, Cima RR, Larson DW. Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes. J Gastrointest Surg 2024; 28:501-506. [PMID: 38583902 DOI: 10.1016/j.gassur.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.
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Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristen K Rumer
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - William R G Perry
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Cardenas Lara FJ, Cima RR. Robotic-assisted parastomal hernia repair using the Sugarbaker technique. Colorectal Dis 2023; 25:2460-2461. [PMID: 37872877 DOI: 10.1111/codi.16779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/11/2023] [Indexed: 10/25/2023]
Affiliation(s)
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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5
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Mirande MD, McKenna NP, Bews KA, Shawki SF, Cima RR, Brady JT, Colibaseanu DT, Mathis KL, Kelley SR. Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis. Am J Surg 2023; 226:703-708. [PMID: 37567817 DOI: 10.1016/j.amjsurg.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. METHODS A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary + drain, or purse-string closure. The primary outcome was SSI at the former DLI site. RESULTS A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure + drain, and 2.7% for purse-string closure (p = 0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p < 0.0001). CONCLUSIONS This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.
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Affiliation(s)
| | | | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Justin T Brady
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA; Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
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McKenna NP, Bews KA, Behm KT, Habermann EB, Cima RR. Postoperative Venous Thromboembolism in Colon and Rectal Cancer: Do Tumor Location and Operation Matter? J Am Coll Surg 2023; 236:658-665. [PMID: 36728394 DOI: 10.1097/xcs.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. STUDY DESIGN Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. RESULTS A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. CONCLUSIONS When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals.
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Affiliation(s)
- Nicholas P McKenna
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
| | - Katherine A Bews
- The Robert D and Patricia E Kern Center for the Science of Health Care Delivery (Bews, Habermann), Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- The Robert D and Patricia E Kern Center for the Science of Health Care Delivery (Bews, Habermann), Mayo Clinic, Rochester, MN
| | - Robert R Cima
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
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Cima RR, Bearden BA, Kollengode A, Nienow JM, Weisbrod CA, Dowdy SC, Amstutz GJ, Narr BJ. Avoiding Retained Surgical Items at an Academic Medical Center: Sustainability of a Surgical Quality Improvement Project. Am J Med Qual 2022; 37:236-245. [PMID: 34803134 DOI: 10.1097/jmq.0000000000000030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Unintentionally retained surgical items (RSIs) are a serious complication representing a surgical "Never" event. The authors previously reported the process and significant improvement over a 3-year multiphased quality improvement RSI reduction effort that included sponge-counting technology. Herein, they report the sustainability of that effort over the decade following the formal quality improvement project conclusion. This retrospective analysis includes descriptive and qualitative data collected during RSI event root cause analysis. Between January 2009 and December 2019, 640 889 operations were performed with 24 RSIs reported. The resulting RSI rate of 1 per 26 704 operations represent a 486% performance improvement compared to the preintervention rate of 1 per 5500 operations. The interval, in days, between RSI events increased to 160 from 26 during the preintervention phase. Cotton sponges were the most retained RSI despite the use of sponge-counting technology. A significant and sustained reduction in RSI is possible after designing a sustainable comprehensive multidisciplinary effort.
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McKenna NP, Bews KA, Cima RR, Crowson CS, Habermann EB. Validation of a left-sided colectomy anastomotic leak risk score and assessment of diversion practices. Am J Surg 2022; 224:971-978. [DOI: 10.1016/j.amjsurg.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
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Grass F, Storlie CB, Mathis KL, Bergquist JR, Asai S, Boughey JC, Habermann EB, Etzioni DA, Cima RR. Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution. Surg Infect (Larchmt) 2020; 22:523-531. [PMID: 33085571 DOI: 10.1089/sur.2020.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Bergquist
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku Asai
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Judy C Boughey
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David A Etzioni
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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10
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Habermann EB, McKenna NP, Bews KA, Pemberton JH, Albright RC, Cima RR. Preoperative Creatinine is Not Good Enough: Underestimation of Preoperative Renal Dysfunction by Creatinine Alone Has Implications for Acute Kidney Injury Requiring Dialysis and Mortality after Major Oncologic Resection. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Daniels CE, Brown MJ, Berbari EF, O'Horo JJC, Ackerman FK, Kendrick ML, Cima RR. Revamping Inpatient Care for Patients Without COVID-19. Mayo Clin Proc 2020; 95:S41-S43. [PMID: 32948260 PMCID: PMC7392043 DOI: 10.1016/j.mayocp.2020.06.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Craig E Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Brown
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Elie F Berbari
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN.
| | | | | | | | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
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12
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Mazzone A, Strege PR, Gibbons SJ, Alcaino C, Joshi V, Haak AJ, Tschumperlin DJ, Bernard CE, Cima RR, Larson DW, Chua HK, Graham RP, El Refaey M, Mohler PJ, Hayashi Y, Ordog T, Calder S, Du P, Farrugia G, Beyder A. microRNA overexpression in slow transit constipation leads to reduced Na V1.5 current and altered smooth muscle contractility. Gut 2020; 69:868-876. [PMID: 31757880 PMCID: PMC7147984 DOI: 10.1136/gutjnl-2019-318747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/16/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Amelia Mazzone
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter R Strege
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon J Gibbons
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Constanza Alcaino
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vikram Joshi
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Haak
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Cheryl E Bernard
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi K Chua
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mona El Refaey
- Departments of Physiology and Cell Biology, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Department of Internal Medicine, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Peter J Mohler
- Departments of Physiology and Cell Biology, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yujiro Hayashi
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tamas Ordog
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Stefan Calder
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Gianrico Farrugia
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA .,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Arthur Beyder
- Enteric NeuroScience Program (ENSP), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA .,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
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McKenna NP, Bews KA, Al-Refaie WB, Colibaseanu DT, Pemberton JH, Cima RR, Habermann EB. Assessing Malnutrition Before Major Oncologic Surgery: One Size Does Not Fit All. J Am Coll Surg 2020; 230:451-460. [PMID: 32113029 DOI: 10.1016/j.jamcollsurg.2019.12.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types. METHODS The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP's variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity. RESULTS We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type. CONCLUSIONS The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, MN; Surgical Outcomes Program, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Katherine A Bews
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Surgical Outcomes Program, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Waddah B Al-Refaie
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Dorin T Colibaseanu
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Surgical Outcomes Program, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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McKenna NP, Glasgow AE, Cima RR, Gettman MT, Dowdy SC, Crowson CS, Habermann EB. Does This Patient Need Labs? Development and Validation of an Applet to Guide Postoperative Hemoglobin Checks. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lemini R, Spaulding AC, Osagiede O, Cochuyt JJ, Naessens JM, Crandall M, Cima RR, Colibaseanu DT. Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida. Am J Surg 2019; 219:1012-1018. [PMID: 31526510 DOI: 10.1016/j.amjsurg.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/22/2019] [Accepted: 09/08/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.
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Affiliation(s)
- Riccardo Lemini
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Osayande Osagiede
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - James M Naessens
- Division of Health Care Policy and Research and Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Rochester, MN, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Lemini R, Spaulding AC, Osagiede O, Cochuyt JJ, Naessens JM, Crandall M, Cima RR, Colibaseanu DT. Disparities in elective surgery for diverticulitis: Identifying the gap in care. Am J Surg 2019; 218:899-906. [PMID: 30878216 DOI: 10.1016/j.amjsurg.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications. METHODS The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models. RESULTS Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons. CONCLUSIONS Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.
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Affiliation(s)
- Riccardo Lemini
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Osayande Osagiede
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - James M Naessens
- Division of Health Care Policy and Research, Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Rochester, MN, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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McKenna NP, Bews KA, Shariq OA, Habermann EB, Cima RR, Lightner AL. Incision & drainage of perianal sepsis in the immunocompromised: A need for heightened postoperative awareness. Am J Surg 2019; 218:507-513. [PMID: 30739740 DOI: 10.1016/j.amjsurg.2019.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/14/2019] [Accepted: 01/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Incision and drainage of perianal sepsis has appreciable success in the immunocompetent population, but outcomes after incision and drainage in the immunosuppressed population are unknown. METHODS 13,666 patients (n = 930 immunosuppressed) undergoing incision and drainage of perianal sepsis between 2011 and 2015 in the American College of Surgeons National Surgical Quality Improvement Program were identified. The main outcomes were major morbidity, return to the operating room, and mortality. Multivariable analysis was performed for each outcome. RESULTS Sepsis was the most common postoperative complication. Preoperative immunosuppression was an independent risk factor for major morbidity (odds ratio [OR]: 1.6, p < 0.01), return to the operating room (OR: 1.9, p < 0.01), and mortality (OR: 2.6, p < 0.01). CONCLUSIONS Immunosuppression is an independent risk factor for major morbidity, return to the operating room, and mortality. With post-operative sepsis the most common complication, inpatient admission and extended duration antibiotic therapy is warranted in immunosuppressed patients.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, MN, USA; Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Katherine A Bews
- Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA; Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Colibaseanu DT, Osagiede O, McCoy RG, Spaulding AC, Habermann EB, Naessens JM, Perry MF, White LJ, Cima RR. PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS. Endocr Pract 2018; 24:1073-1085. [PMID: 30289302 DOI: 10.4158/ep-2018-0379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Vijayvargiya P, Camilleri M, Cima RR. COL1A1 Mutations Presenting as Descending Perineum Syndrome in a Young Patient With Hypermobility Syndrome. Mayo Clin Proc 2018; 93:386-391. [PMID: 29502568 DOI: 10.1016/j.mayocp.2018.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 02/06/2023]
Abstract
A 22-year-old woman presented with 12 years of progressive constipation; she had increased joint flexibility, hyperextensible skin, and excessive perineal descent on examination. Radiological studies confirmed evidence of rectal evacuation disorder due to descending perineum syndrome, enterocele, and rectocele. In a wide genetic screen (∼611,000 single nucleotide polymorphisms), 4 variations were identified in COL1A1 gene ([rs72656352, Chr17: 50,185,535-50,185,539, deletion], [rs72654794, Chr17: 50,188,575, deletion], [rs72667023, Chr17: 50,198,170, deletion], [rs67828806, Chr17: 50,198,177 G→C]). These mutations result in an increase in the number of base pairs in the C' end, as well as replacement of the glycine amino acid in the N' end, leading to incomplete cleavage of procollagen by proteases and resulting in collagen weakness. Our observations suggest that COL1A1 gene mutations are plausible biological factors predisposing to descending perineum syndrome in association with joint hypermobility in this patient.
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Affiliation(s)
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
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Baek SJ, Lightner AL, Boostrom SY, Mathis KL, Cima RR, Pemberton JH, Larson DW, Dozois EJ. Functional Outcomes Following Laparoscopic Ileal Pouch-Anal Anastomosis in Patients with Chronic Ulcerative Colitis: Long-Term Follow-up of a Case-Matched Study. J Gastrointest Surg 2017; 21:1304-1308. [PMID: 28470559 DOI: 10.1007/s11605-017-3411-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA. METHODS A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively. RESULTS One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031). CONCLUSION Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort.
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Affiliation(s)
- Se-Jin Baek
- Division of Colon and Rectal Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Cima RR, Bergquist JR, Hanson KT, Thiels CA, Habermann EB. Outcomes are Local: Patient, Disease, and Procedure-Specific Risk Factors for Colorectal Surgical Site Infections from a Single Institution. J Gastrointest Surg 2017; 21:1142-1152. [PMID: 28470562 DOI: 10.1007/s11605-017-3430-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/10/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Colorectal surgical site infections (SSIs) contribute to postoperative morbidity, mortality, and resource utilization. Risk factors associated with colorectal SSI are well-documented. However, quality improvement efforts are informed by national data, which may not identify institution-specific risk factors. METHOD Retrospective cohort study of colorectal surgery patients uses institutional ACS-NSQIP data from 2006 through 2014. ACS-NSQIP data were enhanced with additional variables from medical records. Multivariable logistic regression identified factors associated with SSI development. RESULTS Of 2376 patients, 213 (9.0%) developed at least one SSI (superficial 4.8%, deep 1.1%, organ space 3.5%). Age < 40, BMI > 30, ASA3+, steroid use, smoking, diabetes, pre-operative sepsis, higher wound class, elevated WBC or serum glutamic-oxalocetic transaminase, low hematocrit or albumin, Crohn's disease, and prolonged incision-to-closure time were associated with increased SSI rate (all P < 0.01). After adjustment, BMI > 30, steroids, diabetes, and wound contamination were associated with SSI. Patients with Crohn's had greater odds of SSI than other indications. CONCLUSION Institutional modeling of SSI suggests that many previously suggested risk factors established on a national level do not contribute to SSIs at our institution. Identification of institution-specific predictors of SSI, rather than relying upon conclusions derived from external data, is a critical endeavor in facilitating quality improvement and maximizing value of quality investments.
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Affiliation(s)
- Robert R Cima
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA. .,Surgical Outcomes Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
| | - John R Bergquist
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.,Surgical Outcomes Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Kristine T Hanson
- Surgical Outcomes Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Cornelius A Thiels
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.,Surgical Outcomes Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Elizabeth B Habermann
- Surgical Outcomes Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Lightner AL, Glasgow AE, Habermann EB, Cima RR. Returns to Operating Room After Colon and Rectal Surgery in a Tertiary Care Academic Medical Center: a Valid Measure of Surgical Quality? J Gastrointest Surg 2017; 21:1048-1054. [PMID: 28342119 DOI: 10.1007/s11605-017-3403-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/10/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Returns to the operating room (ROR) have been suggested as a marker of surgical quality. Increasingly, quality and value metrics are utilized for reimbursement as well as public reporting to inform health care consumers. We sought to understand the etiology of ROR and assess the validity of simple ROR as a quality metric. METHODS This was a single referral center retrospective review of all colon and rectal operations between January 1, 2014 and December 31, 2014. Surgical Systems Nurse + was constructed and validated at our institution for classifying ROR as either an unplanned return to the OR, planned return due to complications, planned staged return, or an unrelated return. The primary outcome was the classification of ROR and total number of ROR within 30 days. RESULTS Of the 2389 colorectal patients who underwent surgery between January 1, 2014 and December 31, 2014; 214 returned to the operating room within 30 days (9.0%). Among the 214 patients, there were a total of 232 ROR with an average of 1.1 ROR per patient (range 1-4); 90 (38.8%) were unplanned ROR, 49 (21.1%) were planned returns due to complications, 92 (39.7%) were planned staged returns, and 1 (0.4%) were unrelated ROR. The most common reason for an unplanned ROR was an anastomotic leak (n = 21; 9.1%). Overall, unplanned reoperations were rare events (n = 90/2389; 3.8%), largely comprised of patients experiencing an anastomotic abscess or leak (n=21/2389; 0.9%). CONCLUSIONS In a high volume and complexity academic colon and rectal surgery practice, RORs within 30 days occurred after 10.4% of cases. Unplanned ROR were relatively rare and most commonly associated with an anastomotic leak. Since the majority of ROR were planned-staged returns, overall rate of ROR should be questioned as a metric of surgical quality. Perhaps, the anastomotic leak rate may be a better metric to monitor for quality improvement efforts.
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Affiliation(s)
- Amy L Lightner
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA. .,Mayo Clinic, Gonda 9S, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Amy E Glasgow
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Upadhyaya SG, Murphree DH, Ngufor CG, Knight AM, Cronk DJ, Cima RR, Curry TB, Pathak J, Carter RE, Kor DJ. Automated Diabetes Case Identification Using Electronic Health Record Data at a Tertiary Care Facility. Mayo Clin Proc Innov Qual Outcomes 2017; 1:100-110. [PMID: 30225406 PMCID: PMC6135013 DOI: 10.1016/j.mayocpiqo.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective To develop and validate a phenotyping algorithm for the identification of patients with type 1 and type 2 diabetes mellitus (DM) preoperatively using routinely available clinical data from electronic health records. Patients and Methods We used first-order logic rules (if-then-else rules) to imply the presence or absence of DM types 1 and 2. The “if” clause of each rule is a conjunction of logical and, or predicates that provides evidence toward or against the presence of DM. The rule includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes, outpatient prescription information, laboratory values, and positive annotation of DM in patients’ clinical notes. This study was conducted from March 2, 2015, through February 10, 2016. The performance of our rule-based approach and similar approaches proposed by other institutions was evaluated with a reference standard created by an expert reviewer and implemented for routine clinical care at an academic medical center. Results A total of 4208 surgical patients (mean age, 52 years; males, 48%) were analyzed to develop the phenotyping algorithm. Expert review identified 685 patients (16.28% of the full cohort) as having DM. Our proposed method identified 684 patients (16.25%) as having DM. The algorithm performed well—99.70% sensitivity, 99.97% specificity—and compared favorably with previous approaches. Conclusion Among patients undergoing surgery, determination of DM can be made with high accuracy using simple, computationally efficient rules. Knowledge of patients’ DM status before surgery may alter physicians’ care plan and reduce postsurgical complications. Nevertheless, future efforts are necessary to determine the effect of first-order logic rules on clinical processes and patient outcomes.
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Key Words
- CCW, Chronic Condition Data Warehouse
- DDC, Durham Diabetes Coalition
- DM, diabetes mellitus
- EHR, electronic health record
- HbA1c of NYC, Hemoglobin A1c of New York City
- HbA1c, hemoglobin A1c
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- MICS, Mayo Integrated Clinical Systems
- NLP, natural language processing
- SUPREME-DM, Surveillance, Prevention, and Management of Diabetes Mellitus
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- eMERGE, Electronic Medical Records and Genomics
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Affiliation(s)
| | | | - Che G Ngufor
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alison M Knight
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daniel J Cronk
- Department of Information Technology, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Timothy B Curry
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | | | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. In Brief. Curr Probl Surg 2017. [DOI: 10.1067/j.cpsurg.2017.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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Lightner AL, Raffals LE, Mathis KL, Cima RR, Tse CS, Pemberton JH, Dozois EJ, Loftus EV. Postoperative Outcomes in Vedolizumab-Treated Patients Undergoing Abdominal Operations for Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:185-190. [PMID: 27543504 DOI: 10.1093/ecco-jcc/jjw147] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Vedolizumab was recently approved by the Food and Drug Administration for the treatment of moderate to severe ulcerative colitis [UC] and Crohn's disease [CD]. No study to date has examined the rate of postoperative infectious complications among patients who received vedolizumab in the perioperative period. We sought to determine the 30-day postoperative infectious complication rate among inflammatory bowel disease [IBD] patients who received vedolizumab within 12 weeks of an abdominal operation as compared to patients who received tumour necrosis factor α [TNFα] inhibitors or no biological therapy. METHODS A retrospective chart review between May 1, 2014 and December 31, 2015 of adult IBD patients who underwent an abdominal operation was performed. The study cohort comprised patients who received vedolizumab within 12 weeks of their abdominal operation and the control cohorts were patients who received TNFα inhibitors or no biological therapy. RESULTS In total, 94 patients received vedolizumab within 12 weeks of an abdominal operation. Fifty experienced postoperative complications [53%], 35 of which were surgical site infections [SSIs] [36%]. The vedolizumab group experienced significantly higher rates of any postoperative infection [53% vs 33% anti-TNF and 28% non-biologics; p<0.001] and SSI [37% vs 10% and 13%; p<0.001]. On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative SSI [p<0.001]. CONCLUSIONS Thirty-seven per cent of IBD patients who received vedolizumab within 30 days of a major abdominal operation experienced a 30-day postoperative SSI, significantly higher than patients receiving TNFα inhibitors or no biological therapy. Vedolizumab within 12 weeks of surgery remained the only predictor of 30-day postoperative SSI on multivariate analysis.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chung Sang Tse
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Sebastian AS, Polites SF, Glasgow AE, Habermann EB, Cima RR, Kakar S. Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery. J Hand Surg Am 2017; 42:10-15.e1. [PMID: 27889092 DOI: 10.1016/j.jhsa.2016.09.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 09/15/2016] [Accepted: 09/23/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | | | - Amy E Glasgow
- Department of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | | | - Robert R Cima
- Department of General Surgery, Mayo Clinic, Rochester, MN
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
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Choudhry AJ, Thiels C, Haddad NN, Cima RR, Habermann EB, Jenkins DH, Zielinski MD. Retained Foreign Objects: Lessons Learned from 30 years of Medical Litigation. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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31
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Thiels C, Glasgow A, Bergquist JR, Hanson KT, Cima RR, Etzioni DA, Zielinski MD, Habermann EB, Hyder JA. Travel Distance and Patient Experience for Oncologic Surgery: An Analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wanta BT, Glasgow AE, Habermann EB, Kor DJ, Cima RR, Berbari EF, Curry TB, Brown MJ, Hyder JA. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. Surg Infect (Larchmt) 2016; 17:755-760. [PMID: 27598433 DOI: 10.1089/sur.2016.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) contribute to surgical patients' morbidity and costs. Operating room traffic may be a modifiable risk factor for SSI. We investigated the impact of additional operating room personnel on the risk of superficial SSI (sSSI). PATIENTS AND METHODS In this matched case-control study, cases included patients in whom sSSI developed in clean surgical incisions after elective, daytime operations. Control subjects were matched by age, gender, and procedure. Operating room personnel were classified as (1) surgical scrubbed, (2) surgical non-scrubbed, or (3) anesthesia. We used conditional logistic regression to test the extent to which additional personnel overall and from each work group were associated with infection. RESULTS In total, 474 patients and 803 control subjects were identified. Each additional person among total personnel and personnel from each work group was significantly associated with greater odds of infection (all personnel, odds ratio [OR] = 1.082, 95% confidence interval [CI] 1.031-1.134, p = 0.0013; surgical scrubbed OR = 1.132, 95% CI 1.029-1.245, p = 0.0105; surgical non-scrubbed OR = 1.123, 95% CI 1.008-1.251, p = 0.0357; anesthesia OR = 1.153, 95% CI 1.031-1.290, p = 0.0127). After adjusting for operative duration, body mass index, diabetes mellitus, and vascular disease, additional personnel and sSSI were no longer associated overall or for any work groups (total personnel OR = 1.033, 95% CI 0.974-1.095, p = 0.2746; surgical scrubbed OR = 1.060, 95% CI 0.952-1.179, p = 0.2893; surgical non-scrubbed OR = 1.023 95% CI 0.907-1.154, p = 0.7129; anesthesia OR = 1.051, 95% CI 0.926-1.193, p = 0.4442). CONCLUSION The presence of additional operating room personnel was not independently associated with increased odds of sSSI. Efforts dedicated to sSSI reduction should focus on other modifiable risk factors.
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Affiliation(s)
- Brendan T Wanta
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Amy E Glasgow
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota
| | - Elizabeth B Habermann
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota.,3 Department of Health Sciences Research, Division of Health Care Research and Policy, Mayo Clinic , Rochester, Minnesota
| | - Daryl J Kor
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Robert R Cima
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota.,4 Department of Surgery, Division of Colorectal Surgery, Mayo Clinic , Rochester, Minnesota
| | - Elie F Berbari
- 5 Department of Medicine, Division of Infectious Diseases, Mayo Clinic , Rochester, Minnesota
| | - Timothy B Curry
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota.,6 Department of Medicine, Division of Physiology, Mayo Clinic , Rochester, Minnesota
| | - Michael J Brown
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Joseph A Hyder
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota.,2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota
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Erenay FS, Alagoz O, Banerjee R, Said A, Cima RR. Cost-effectiveness of alternative colonoscopy surveillance strategies to mitigate metachronous colorectal cancer incidence. Cancer 2016; 122:2560-70. [PMID: 27248907 DOI: 10.1002/cncr.30091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Fatih Safa Erenay
- Department of Management Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Adnan Said
- Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
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Baek SJ, Dozois EJ, Mathis KL, Lightner AL, Boostrom SY, Cima RR, Pemberton JH, Larson DW. Safety, feasibility, and short-term outcomes in 588 patients undergoing minimally invasive ileal pouch-anal anastomosis: a single-institution experience. Tech Coloproctol 2016; 20:369-374. [PMID: 27118465 DOI: 10.1007/s10151-016-1465-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/16/2016] [Indexed: 01/10/2023]
Abstract
PURPOSE A laparoscopic approach to proctocolectomy and ileal pouch-anal anastomosis (IPAA) in patients with chronic ulcerative colitis and familial adenomatous polyposis has grown in popularity secondary to reports of small series demonstrating short-term patient benefits. Limited data exist in large numbers of patients undergoing laparoscopic ileal pouch-anal anastomosis (L-IPAA). We aimed to analyze surgical outcomes in a large cohort of patients undergoing L-IPAA. METHODS From a prospectively maintained surgical database, 30-day surgical outcome data were reviewed for all L-IPAA performed for chronic ulcerative colitis and familial adenomatous polyposis from 1999 to 2012. Demographics, operative approach, and operative and postoperative complications were analyzed. RESULTS A total of 588 L-IPAA ileal pouch-anal anastomoses were performed predominantly for chronic ulcerative colitis (93.9 %). The mean age was 36.2 years, and 54.3 % were male, with a mean BMI of 24.1 kg/m(2). Three-stage operations were performed in 17.7 %. The mean operating time of the patients excluding 3-stage operation was 269.4 min. Minimally invasive techniques included hand-assist in 55 % and straight laparoscopy in 45 %. Conversion to open occurred in 8.8 %. Median length of stay was 5 days. There was no mortality. Complications occurred in 36.9 % of patients: Clavien grade I (17.5 %), grade II (72.8 %), and grade III (9.7 %). Analysis of the grouped data over time demonstrated a statistically significant reduction in operative time (p < 0.001) and an increase in the ratio of hand-assisted over straight laparoscopy (p = 0.001). CONCLUSIONS Minimally invasive IPAA performed using either a laparoscopic or hand-assisted technique is safe, can be performed with low conversion rates, and confers beneficial perioperative outcomes.
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Affiliation(s)
- S-J Baek
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - E J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - A L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - S Y Boostrom
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - R R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - J H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Bergquist JR, Thiels CA, Etzioni DA, Habermann EB, Cima RR. Failure of Colorectal Surgical Site Infection Predictive Models Applied to an Independent Dataset: Do They Add Value or Just Confusion? J Am Coll Surg 2016; 222:431-8. [DOI: 10.1016/j.jamcollsurg.2015.12.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023]
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Hyder JA, Bohman JK, Kor DJ, Subramanian A, Bittner EA, Narr BJ, Cima RR, Montori VM. Anesthesia Care Transitions and Risk of Postoperative Complications. Anesth Analg 2016; 122:134-44. [PMID: 25794111 DOI: 10.1213/ane.0000000000000692] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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37
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Lightner AL, Cima RR. Reoperative Crohn׳s surgery: Lessons learned the hard way. Seminars in Colon and Rectal Surgery 2015. [DOI: 10.1053/j.scrs.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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38
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Cima RR, Dhanorker SR, Ostendorf CL, Ntekpe M(SS, Mudundi RV, Habermann EB, Deschamps C. Returns to operating room (ROR) in a tertiary care academic medical center: a measure of complexity, complications or both? An electronic tool to identify the reality regarding RORS. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neshatian L, Strege PR, Rhee PL, Kraichely RE, Mazzone A, Bernard CE, Cima RR, Larson DW, Dozois EJ, Kline CF, Mohler PJ, Beyder A, Farrugia G. Ranolazine inhibits voltage-gated mechanosensitive sodium channels in human colon circular smooth muscle cells. Am J Physiol Gastrointest Liver Physiol 2015; 309:G506-12. [PMID: 26185330 PMCID: PMC4572410 DOI: 10.1152/ajpgi.00051.2015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/09/2015] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Leila Neshatian
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Peter R. Strege
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Poong-Lyul Rhee
- 4Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and
| | - Robert E. Kraichely
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Amelia Mazzone
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Cheryl E. Bernard
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Robert R. Cima
- 3Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - David W. Larson
- 3Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Eric J. Dozois
- 3Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Crystal F. Kline
- 5The Dorothy M. Davis Heart and Lung Research Institute and Departments of Internal Medicine and Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter J. Mohler
- 5The Dorothy M. Davis Heart and Lung Research Institute and Departments of Internal Medicine and Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Arthur Beyder
- 1Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; ,2Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
| | - Gianrico Farrugia
- Enteric NeuroScience Program, Mayo Clinic College of Medicine, Rochester, Minnesota; Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota;
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Dreyer NE, Cutshall SM, Huebner M, Foss DM, Lovely JK, Bauer BA, Cima RR. Effect of massage therapy on pain, anxiety, relaxation, and tension after colorectal surgery: A randomized study. Complement Ther Clin Pract 2015; 21:154-9. [DOI: 10.1016/j.ctcp.2015.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 05/27/2015] [Accepted: 06/05/2015] [Indexed: 11/29/2022]
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Etzioni DA, Wasif N, Mathur AK, Habermann EB, Cima RR, Chang YHH. Impact of Unaccounted Risk Factors on the Interpretation of Surgical Outcomes. J Am Coll Surg 2015; 221:821-7. [PMID: 26253561 DOI: 10.1016/j.jamcollsurg.2015.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systems that report hospital-based risk-adjusted surgical outcomes are potentially sensitive to the underlying methods used for risk adjustment. If a body of operations has a true level of risk that is higher than the estimated risk, then these operations might generate bias in the output of these reports. The objective of this study was to quantify the impact of unaccounted risk on the results of a surgical outcomes report. STUDY DESIGN We constructed a model simulating a universe of 500 hospitals, each providing care to 1,500 patients in a given year. The likelihood of morbidity and mortality for each of these patients was drawn from a random sampling of patients in the American College of Surgeons NSQIP. A single additional hospital was also simulated, within which a certain proportion (proportion varied from 2% to 10%) of patients had a significantly higher (odds ratio varied from 1 to 5) actual likelihood of mortality. RESULTS The presence of even a small proportion (2%) of patients with unaccounted risk had the potential to greatly increase the likelihood of a hospital being considered a statistical outlier (poor performer). This impact was greater in the assessment of complications than mortality. CONCLUSIONS This study shows that even a small proportion of patients with substantial levels of unaccounted risk can have a dramatic impact on the assessment of hospital-level risk-adjusted surgical outcomes. To avoid the unintended consequences associated with risk-averse behavior from providers, policy should be constructed to address this potential source of bias.
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Affiliation(s)
- David A Etzioni
- Department of Surgery, Mayo Clinic, Phoenix, AZ; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN.
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic, Phoenix, AZ; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, AZ; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN
| | - Elizabeth B Habermann
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN
| | - Robert R Cima
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Yu-Hui H Chang
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Branch, Rochester, MN
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Thiels CA, Lal TM, Nienow JM, Pasupathy KS, Blocker RC, Aho JM, Morgenthaler TI, Cima RR, Hallbeck S, Bingener J. Surgical never events and contributing human factors. Surgery 2015; 158:515-21. [PMID: 26032826 DOI: 10.1016/j.surg.2015.03.053] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/26/2015] [Accepted: 03/12/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS). METHODS From August 2009 to August 2014, operative and invasive procedural "Never Events" (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using the 4 levels of error causation described by Reason and 161 HFACS subcategories (nano-codes). RESULTS During the study, approximately 1.5 million procedures were performed, during which 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors (n = 260) and preconditions to actions (n = 296) accounted for the majority of the nano-codes across all 4 types of events, with individual cognitive factors contributing one half of the nano-codes. The most common action nano-codes were confirmation bias (n = 36) and failed to understand (n = 36). The most common precondition nano-codes were channeled attention on a single issue (n = 33) and inadequate communication (n = 30). CONCLUSION Targeting quality and interventions in system improvement addressing cognitive factors and team resource management as well as perceptual biases may decrease errors and further improve patient safety. These results delineate targets to further decrease never events from our health care system.
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Affiliation(s)
| | - Tarun Mohan Lal
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Kalyan S Pasupathy
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Renaldo C Blocker
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | | | - Susan Hallbeck
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Badjie KSW, Rogers JC, Jenkins SM, Bundy KL, Stubbs JR, Cima RR. Safe transition to surgery: working differently to make blood transfusion process safer for elective surgery. Transfusion 2015; 55:2238-45. [PMID: 25854123 DOI: 10.1111/trf.13108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/10/2015] [Accepted: 02/25/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our institutional policy allows patients who are scheduled for elective surgery with no history of a pregnancy or blood transfusion in the preceding 3 months to have a presurgical sample (PSS) collected and tested up to 56 days before their scheduled surgery; however, our PSS TS completion rate in eligible patients before the morning of surgery was 83%. In 2011, a team was charged to develop a standardized process along with other process improvements while ensuring no increase in transfusion-related events. STUDY DESIGN AND METHODS The team followed the DMAIC framework in appraising the effectiveness and efficiency of the current state process including baseline data collection such as PSS TS completion rate, number of eligible patients needing a PSS TS on the day of surgery, benchmarking, SSBO utilization, and future state mapping. RESULTS First quarter (Q1) 2011 versus Q1 2012 postimplementation results showed significant improvements of the process including a 53% decrease in PSS TS on the day of surgery; a 13% increase in PSS TS completion before the morning of surgery; a 26% reduction in total XM RBCs; and a 58.8% reduction in XM RBCs not issued, plus a 47% decrease in RBC wastage. Q1 2011 versus Q1 2013 showed a 41% reduction in total XM RBCs and an 88.4% reduction in XM RBCs not issued but overall RBCs issued versus returned increased slightly and represents a future opportunity for improvement. CONCLUSIONS The redesigned, transformational process eliminated SSBO and improved ordering process and PSS TS completion rate as well as blood product ordering and utilization.
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Affiliation(s)
- Karafa S W Badjie
- Department of Laboratory Medicine and Pathology Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - James C Rogers
- Systems and Procedures, Mayo Clinic, Rochester, Minnesota
| | - Sarah M Jenkins
- Department of Health Sciences Research, Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Bundy
- Department of Laboratory Medicine and Pathology Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - James R Stubbs
- Department of Laboratory Medicine and Pathology Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert R Cima
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota.,Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Polites SF, Habermann EB, Zarroug AE, Wagie AE, Cima RR, Wiskerchen R, Moir CR, Ishitani MB. A comparison of two quality measurement tools in pediatric surgery--the American College of Surgeons National Surgical Quality Improvement Program-Pediatric versus the Agency for Healthcare Research and Quality Pediatric Quality Indicators. J Pediatr Surg 2015; 50:586-90. [PMID: 25840068 DOI: 10.1016/j.jpedsurg.2014.10.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 10/15/2014] [Accepted: 10/15/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Identifying quality in pediatric surgery can be difficult given the low frequency of postoperative complications. We compared postoperative events following pediatric surgical procedures at a single institution identified by ACS-NSQIP Pediatric (ACS NSQIP-P) methodology and AHRQ Pediatric Quality Indicators (AHRQ PDIs), an administrative tool. METHODS AHRQ PDI algorithms were run on inpatient hospital discharge abstracts for 1257 children in the 2010 to 2013 ACS NSQIP-P at our institution. Four events-pulmonary complications, postoperative sepsis, wound dehiscence and bleeding-were matched between ACS NSQIP-P and AHRQ PDI. RESULTS Events were identified by ACS NSQIP-P in 7.9% of children and by AHRQ PDI in 8.0%. The four matched events were identified in 5.5% and 3.7%, respectively. Specificities of AHRQ PDI ranged from 97% to 100% and sensitivities from 0 to 2%. The largest discrepancy was in bleeding, where AHRQ PDI captured 1 of the 54 events identified by ACS NSQIP-P. None of the 41 pulmonary, sepsis, and wound dehiscence events identified by AHRQ PDI were clinically relevant according to ACS NSQIP-P. CONCLUSIONS Adverse events following pediatric surgery are infrequent; thus, additional measures of quality to supplement postoperative adverse events are needed. AHRQ PDIs are inadequate for assessing quality in pediatric surgery.
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Affiliation(s)
| | - Elizabeth B Habermann
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Abdalla E Zarroug
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amy E Wagie
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States
| | - Michael B Ishitani
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States.
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Hyder JA, Niconchuk J, Glance LG, Neuman MD, Cima RR, Dutton RP, Nguyen LL, Fleisher LA, Bader AM. What can the national quality forum tell us about performance measurement in anesthesiology? Anesth Analg 2015; 120:440-8. [PMID: 25602454 DOI: 10.1213/ane.0000000000000553] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. METHODS We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream. RESULTS Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards. CONCLUSIONS Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.
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Affiliation(s)
- Joseph A Hyder
- From the *Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; †Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee; ‡Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York; §Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania; ∥Department of Surgery, Mayo Clinic, Rochester, Minnesota; ¶Anesthesia Quality Institute, Park Ridge, Illinois; #Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; **Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts; ††Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania; and ‡‡Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Wise KB, Merchea A, Cima RR, Colibaseanu DT, Thomsen KM, Habermann EB. Proximal intestinal diversion is associated with increased morbidity in patients undergoing elective colectomy for diverticular disease: an ACS-NSQIP study. J Gastrointest Surg 2015; 19:535-42. [PMID: 25416544 DOI: 10.1007/s11605-014-2700-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/07/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Elective colectomy for diverticular disease is common. Some patients undergo primary resection with proximal diversion in an effort to limit morbidity associated with potential anastomotic leak. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried. All patients undergoing a single, elective resection for diverticular disease from 2005 to 2011 were analyzed. Thirty-day outcomes were reviewed. Factors predictive of undergoing diversion and the risk-adjusted odds of postoperative morbidity with and without proximal diversion were determined by multivariable logistic regression models. RESULTS Fifteen thousand six hundred two patients undergoing non-emergent, elective resection were identified, of whom 348 (2.2 %) underwent proximal diversion. Variables predictive for undergoing proximal diversion included age ≥65 years, BMI ≥30, current smoking status, corticosteroid use, and serum albumin <3.0 g/dL. Multivariable analysis demonstrated that diversion was associated with significantly increased risk of surgical site infection (OR = 1.68), deep venous thrombosis (OR = 5.27), acute renal failure (OR = 5.83), sepsis or septic shock (OR = 1.75), readmission (OR = 2.57), and prolonged length of stay (OR = 3.35). CONCLUSIONS Proximal diversion in the setting of elective segmental colectomy for diverticular disease is uncommon. A combination of preoperative factors and intraoperative factors drives the decision for diversion. Patients who undergo diversion experience increased postoperative morbidity. Surgeons should have a low index of suspicion for postoperative complications and be prepared to mitigate their effect on the patient's outcome.
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Affiliation(s)
- Kevin B Wise
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Etzioni DA, Wasif N, Dueck AC, Cima RR, Hohmann SF, Naessens JM, Mathur AK, Habermann EB. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA 2015; 313:505-11. [PMID: 25647206 DOI: 10.1001/jama.2015.90] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- David A Etzioni
- Department of Surgery, Mayo Clinic Arizona, Phoenix2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic Arizona, Phoenix2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
| | - Amylou C Dueck
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
| | - Robert R Cima
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona3Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Samuel F Hohmann
- University HealthSystem Consortium, Chicago, Illinois5Department of Health Systems Management, Rush University, Chicago, Illinois
| | - James M Naessens
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Division, Phoenix, Arizona
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Chu DI, Schlieve CR, Colibaseanu DT, Simpson PJ, Wagie AE, Cima RR, Habermann EB. Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies. J Gastrointest Surg 2015; 19:327-34. [PMID: 25217092 DOI: 10.1007/s11605-014-2649-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/27/2014] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1720 2nd Avenue South, KB427, Birmingham, AL, 35294, USA,
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Thomsen KM, Polites S, Nehring SA, Shubert CR, Etzioni DA, Cima RR, Habermann EB. Unplanned Related Readmissions after Colectomy for Colorectal Cancer: Insights using the 2012 American College of Surgeons (ACS) NSQIP Data. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shubert CR, Habermann EB, Bergquist JR, Thomsen KM, Kendrick ML, Cima RR, Nagorney DM. A NSQIP Review of Major Morbidity and Mortality of Synchronous Liver Resection for Colorectal Metastasis Stratified by Extent of Liver Resection and Type of Colorectal Resection. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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