John C. Byrn

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database.

Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States.

Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation

Background: Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors. Methods: We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk‐adjusted rates of anastomotic leak. Results: Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra‐abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 109/L), and urgent/emergency operations were independently associated with anastomotic leak (C‐statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak. Conclusion: This population‐based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.

A matched case-control study of IBD-associated colorectal cancer: IBD portends worse outcome

The effect of inflammatory bowel disease (IBD) on outcome in patients with colorectal cancer (CRC) remains unclear. Our objective is to evaluate oncologic outcomes of patients with IBD‐associated CRC.

Effect of BMI on outcomes in proctectomy.

BACKGROUND: The unique surgical challenges of proctectomy may be amplified in obese patients. We examined surgical outcomes of a large, diverse sample of obese patients undergoing proctectomy. OBJECTIVE: The purpose of this work was to determine whether increased BMI is associated with increased complications in proctectomy. DESIGN: This was a retrospective review. SETTINGS: The study uses the American College of Surgeons National Surgical Quality Improvement Program database (2010 and 2011). PATIENTS: Patients included were those undergoing nonemergent proctectomy, excluding rectal prolapse cases. Patients were grouped by BMI using the World Health Organization classifications of underweight (BMI <18.5); normal (18.5-24.9); overweight (25.0-29.9); and class I (30.0-34.9), class II (35.0-39.9), and class III (≥40.0) obesity. MAIN OUTCOME MEASURES: We analyzed the effect of preoperative and intraoperative factors on 30-day outcomes. Continuous variables were compared with Wilcoxon rank-sum tests and proportions with the Fisher exact or &khgr;2 tests. Logistic regression controlled for the effects of multiple risk factors. RESULTS: Among 5570 patients, class I, II, and III obesity were significantly associated with higher rates of overall complications (44.0%, 50.8%, and 46.6% vs 38.1% for normal-weight patients; p < 0.05). Superficial wound infection was significantly higher in classes I, II, and III (11.6%, 17.8%, and 13.0% vs 8.0% for normal-weight patients; p < 0.05). Operative times for patients in all obesity classes were significantly longer than for normal-weight patients. On multivariate analysis, an obese BMI independently predicted complications; ORs (95% CIs) were 1.36 (1.14-1.62) for class I obesity, 1.99 (1.54-2.54) for class II, and 1.42 (1.02-1.96) for class III. LIMITATIONS: This study was a retrospective design with limited follow-up. CONCLUSIONS: Class I, II, and III obese patients were at significantly increased risk for morbidity compared with normal BMI patients. Class II obese patients had the highest rate of complications, a finding that deserves further investigation.

Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative

Importance Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons. Objective To assess rates of complications for MIC compared with OC among surgeons. Design, Setting, and Participants We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches. Main Outcomes and Measures Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC. Results Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC. Conclusions and Relevance Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Differences in short-term outcomes among patients undergoing IPAA with or without preoperative radiation: a National Surgical Quality Improvement Program analysis.

BACKGROUND: Single-institution studies demonstrate a correlation between preoperative pelvic radiation and poor long-term pouch function after IPAA. The rarity of the radiated pelvis before these procedures limits the ability to draw conclusions on the effects of preoperative radiation on short-term outcomes, which may contribute to long-term pouch dysfunction. OBJECTIVE: The purpose of this work was to better understand the impact of pelvic radiation on short-term outcomes in patients undergoing IPAA. DESIGN: We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005–2011). SETTINGS: The study was conducted at all participating NSQIP institutions. PATIENTS: The cohort was composed of patients undergoing nonemergent IPAA procedures. MAIN OUTCOME MEASURES: Proportions of patients experiencing postoperative complications within 30 days were compared by Fisher exact and Wilcoxon rank-sum tests based on whether they received preoperative radiation. Multivariate logistic regression models controlled for the effects of multiple risk factors. RESULTS: Included were 3172 patients receiving IPAA; 162 received pelvic radiation. The postoperative complication rate was not significantly different in patients receiving pelvic radiation versus not receiving pelvic radiation (p = 0.06). In a subset of patients with cancer diagnoses (n = 598), 157 received pelvic radiation; complication rates were not significantly different (p = 0.16). Patients receiving pelvic radiation had significantly lower rates of sepsis in both the overall and cancer diagnosis groups (p = 0.005 and p = 0.047), a finding which persisted after controlling for the effects of multiple risk factors (multivariate p values = 0.030 and 0.047). LIMITATIONS: This was a retrospective database design with short-term follow-up. CONCLUSIONS: Patients who received radiation before IPAA had no difference in overall 30-day complication rates but had significantly lower rates of sepsis when compared with patients not receiving pelvic radiation. The perceived inferior long-term pouch function in patients undergoing preoperative pelvic radiation does not appear to be attributable to increases in 30-day complications.

Impact of urinary tract infection definitions on colorectal outcomes

BACKGROUND Hospital-acquired urinary tract infections (UTIs) significantly impact hospital outcomes. Colorectal surgery is inherently high risk for postoperative infections including UTI, and these patients may have unique outcomes as compared to other medical and surgical hospitalizations. We aim to assess the impact of the differing definitions of UTI captured by our hospital quality measures on hospital charges, length of stay (LOS), and mortality after colorectal resections at our institution. MATERIALS AND METHODS Existing hospital quality surveillance was used to retrospectively identify postcolorectal resection UTI, as defined by the National Surgical Quality Improvement Program (NSQIP), and the Centers for Disease Control and Preventions National Healthcare Safety Network (NHSN)-defined catheter-associated UTIs (CAUTI), from 2006-2012. Both groups were compared to colorectal resections performed during the same period that did not develop a UTI. Groups were compared for differences in 30-d surgical outcomes with multivariate analysis of total hospital charges and LOS. RESULTS During our study period, we identified 18 CAUTIs and 42 NSQIP-UTI, and 1064 other colorectal resections (UTI rate, 5.3%). Our overall mortality rate was 4.4% and was not associated with CAUTI or NSQIP-UTI on univariate analysis. CAUTI, but not NSQIP-UTI, was associated with a 73% increase in LOS and 70% increase in total hospital charges on multivariate analysis. CONCLUSIONS By reviewing quality outcomes surveillance modalities at our hospital, we identified postcolorectal resection CAUTI, but not NSQIP-UTI, to be associated with increased total hospital charges and LOS. Neither was associated with mortality.

Technical considerations in laparoscopic total proctocolectomy.

Total proctocolectomy, whether restorative or terminating with an end ileostomy, is an advanced laparoscopic procedure. The goal of this publication is to address specific techniques unique to the operation of laparoscopic total proctocolectomy and review the basics of laparoscopic colon and rectal resections. As in all complex operations, proficiency and efficiency in performing the laparoscopic total proctocolectomy comes with a step-wise approach. Respectable operating room times and true patient benefits may take more than safe reliable, technique; however, and only after a significant experience has been gained will the learning curve plateau.

Single-incision robotic colectomy: are costs prohibitive?

The feasibility, safety, and costs of single‐incision robotic colectomy (SIRC) are not known.

Laparoscopic Abdominoperineal Resection

Laparoscopic abdominoperineal resection is performed in selected cases of malignancy of the anus/rectum when a sphincter sparing procedure is not feasible. This chapter lists the indications, essential steps, common technical variations, and complications of the operation. A detailed operative dictation note template is included.