Donald Kim

Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program.

INTRODUCTION: No consensus exists regarding the optimal fluid (crystalloid or colloid) or strategy (liberal, restricted, or goal directed) for fluid management after colectomy. Prior assessments have used normal saline. This is the first assessment of standard, goal-directed perioperative fluid management with either lactated Ringer’s or hetastarch/lactated Ringer’s, with use of esophageal Doppler for guidance, in laparoscopic colectomy with an enhanced recovery protocol. METHODS: A double-blinded, prospective, randomized, three-armed study with Institutional Review Board approval was used for patients undergoing laparoscopic segmental colectomy assigned to the standard, goal-directed/lactated Ringer’s and goal-directed/hetastarch groups. A standard anesthesia and basal fluid administration protocol was used in addition to the goal-directed strategies guided by esophageal Doppler. RESULTS: Sixty-four patients undergoing laparoscopic colectomy (22 standard, 21 goal-directed/lactated Ringer’s, 21 goal-directed/hetastarch) had similar operative times (standard, 2.3 hours; goal-directed/lactated Ringer’s, 2.5 hours; goal-directed/hetastarch, 2.3 hours). The lactated Ringer’s group received the greatest amount of total and milliliters per kilogram per hour of operative fluid (standard, 2,850/18; goal-directed/lactated Ringer’s, 3,800/23; and goal-directed/hetastarch, 3,300/17; P < 0.05). The hetastarch group had the longest stay (standard, 64.9 hours; goal-directed/lactated Ringer’s, 71.8 hours; goal-directed/hetastarch, 75.5 hours; P < 0.05). The standard group received the greatest amount of fluid during hospitalization (standard, 2.5 ml/kg/h; goal-directed/lactated Ringer’s, 1.9 ml/kg/h; goal-directed/hetastarch, 2.1 ml/kg/h; P < 0.05). There was one instance of operative mortality in the goal-directed/hetastarch group. CONCLUSIONS: Goal-directed fluid management with a colloid/balanced salt solution offers no advantage and is more costly. However, goal-directed, individualized intraoperative fluid management with crystalloid should be evaluated further as a component of enhanced recovery protocols following colectomy because of reduced overall fluid administration.

Colonoscopy in the Office Setting is Safe, and Financially Sound ... For Now

PurposeIn 2000, the Centers for Medicare & Medicaid Services announced a plan to allow for enhanced reimbursement for office endoscopy. This change in reimbursement was phased in during three years. The purpose of this study was to evaluate the fiscal outcomes and quality measures in the first two and a one-half years of performing endoscopy in an office setting under the new Centers for Medicare & Medicaid Services guidelines.MethodsThe following financial parameters were gathered: number of endoscopies, expenses (divided into salaries and operational), net revenue, and margin for endoscopies performed in the office compared with the hospital. All endoscopies were performed by endoscopists with advanced training (gastroenterology fellowship or colon and rectal surgery residency). Monitoring equipment included continuous SaO2 and automated blood pressure in all patients and continuous electrocardiographic monitors in selected patients. Quality/safety data have been tracked in a prospective manner and include number of transfers to the hospital, perforations, bleeding requiring transfusion or hospitalization, and cardiorespiratory arrest.ResultsThe financial outcomes are as follows: 13,285 endoscopies performed from the opening of the unit through December 2003; net revenue per case

Using Value-Based Analysis to Influence Outcomes in Complex Surgical Systems

504 per case; expense per case has dropped from

Minimally Invasive Colorectal Resection Is Associated With a Transient Increase in Plasma Hepatocyte Growth Factor Levels Early After Surgery for Colon Cancer

205 per case to

Anastomotic leaks: technique and timing of detection

145 per case; the overall financial benefit of performing endoscopy in the office compared with the hospital was an additional

Abstract B50: Targeting KRASG12D colorectal cancer with combined inhibition of PI3K/mTOR and MAPK signaling

28 to

Tu1519 High Definition Colonoscopy Increases Adenoma Detection Rate

143 per case depending on the insurance carrier. The quality outcomes since inception of the unit include the following: 13,285 endoscopies; 0 hospital transfers, 0 cardiorespiratory arrests; 0 perforations; and 1 bleeding episode that required hospitalization.ConclusionsEndoscopy performed in the office setting is safe when done with appropriate monitoring and in the proper patient population. At the time of this study, office endoscopy also is financially rewarding but changes in Centers for Medicare & Medicaid Services reimbursement threaten the ability to retain any financial benefit.

728 First Time Colonoscopy in the Elderly Yields a High Rate of Curable Colorectal Cancer

BACKGROUND Value-based analysis (VBA) is a management strategy used to determine changes in value (quality/cost) when a usual practice (UP) is replaced by a best practice (BP). Previously validated in clinical initiatives, its usefulness in complex systems is unknown. To answer this question, we used VBA to correct deficiencies in cardiac surgery at Memorial Healthcare System. STUDY DESIGN Cardiac surgery is a complex surgical system that lends itself to VBA because outcomes metrics provided by the Society of Thoracic Surgeons provide an estimate of quality; cost is available from Centers for Medicare and Medicaid Services and other contemporary sources; the UP can be determined; and the best practice can be established. RESULTS Analysis of the UP at Memorial Healthcare System revealed considerable deficiencies in selection of patients for surgery; the surgery itself, including choice of procedure and outcomes; after care; follow-up; and control of expenditures. To correct these deficiencies, each UP was replaced with a BP. Changes included replacement of most of the cardiac surgeons; conversion to an employed physician model; restructuring of a heart surgery unit; recruitment of cardiac anesthesiologists; introduction of an interactive educational program; eliminating unsafe practices; and reducing cost. CONCLUSIONS There was a significant (p < 0.01) reduction in readmissions, complications, and mortality between 2009 and 2013. Memorial Healthcare System was only 1 of 17 (1.7%) database participants (n = 1,009) to achieve a Society of Thoracic Surgeons 3-star rating in all 3 measured categories. Despite substantial improvements in quality, the cost per case and the length of stay declined. These changes created a savings opportunity of

Implementation of colonoscopic process measures: does it improve quality?

14 million, with actual savings of

A comparison of laparoscopic, hand-assist and open sigmoid resection in the treatment of diverticular disease

10.4 million. These findings suggest that VBA can be a powerful tool to enhance value (quality/cost) in a complex surgical system.