Michael J. Kim

How much do we need to worry about venous thromboembolism after hospital discharge? A study of colorectal surgery patients using the National Surgical Quality Improvement Program database.

PURPOSE: It is well recognized that the increased risk of a postoperative venous thrombotic event extends beyond the inpatient treatment period. The purpose of this study was to determine the 30-day incidence and risk factors associated with the occurrence of early postdischarge symptomatic venous thromboembolic events in patients who have undergone major colorectal surgery. METHODS: The National Surgical Quality Improvement Program database was queried for patients who had undergone a colon or rectal resection during the study period (2005–2008). Patient demographics, preoperative risk factors, and operative variables were recorded. The primary outcomes were occurrence of deep venous thrombosis requiring therapy or pulmonary embolism within 30 days after initial surgery. The occurrence of postdischarge venous thromboembolic events was calculated from the days to primary outcome and days from operation to discharge. Univariate and multivariate linear regression models incorporating pre- and intraoperative variables as well as the occurrence of a major or minor complication were used to evaluate the effect of these clinical factors on the early postdischarge venous thromboembolic event rate. RESULTS: A total of 52,555 patients were included in the initial analysis. A total of 240 deep venous thromboses were diagnosed in the postdischarge setting giving a postdischarge incidence of 0.47%. One hundred thirty cases of a pulmonary embolus were diagnosed (0.26% incidence) with 30 patients having a concurrent deep venous thrombosis and pulmonary embolus. The overall cumulative postdischarge symptomatic venous thromboembolic incidence was 0.67% (n = 340). Obesity, preoperative steroid use, “bleeding disorder,” ASA class III, and postoperative (major and minor) complications were all independently associated with an increased risk of an early postdischarge venous thromboembolic event. CONCLUSION: This study has identified risk factors that may help stratify patients into different risk profiles and offer prolonged prophylaxis to patients at increased risk on the basis of preoperative risk factors and postoperative complications.

A laparoscopic approach does reduce short-term complications in patients undergoing ileal pouch-anal anastomosis.

BACKGROUND: Studies to date examining the impact of laparoscopy in the IPAA have failed to demonstrate a significant, consistent benefit in terms of a reduction in short-term morbidity or length of stay. OBJECTIVE: The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after IPAA formation. DESIGN, SETTING, AND PATIENTS: With use of the American College of Surgeons National Surgical Quality Improvement Program participant use file (2005–2008), the records of patients who underwent open or laparoscopic IPAA with diverting ileostomy were examined. MAIN OUTCOME MEASURES: Risk-adjusted 30-day outcomes and length of stay were assessed by use of regression modeling, adjusting for patient characteristics, comorbidities, and operative approach. RESULTS: Six hundred seventy-six cases were included, of which 339 (50.1%) were laparoscopic procedures. After adjustment, a laparoscopic approach was associated with a lower rate of major (OR = 0.67, 95% CI: 0.45–0.99, P = .04) and minor (OR = 0.44, 95% CI: 0.27–0.70, P = .01) complications. Laparoscopy was not associated with a significant reduction in length of postoperative stay compared with open pouch formation (laparoscopic vs open approach, −0.05 ± 0.30 d (P = .87)). LIMITATIONS: The sampling strategy used by the National Surgical Quality Improvement Program means that only a proportion of all relevant cases would have been analyzed and no data are available about the potential impact of surgeon experience on outcome. CONCLUSIONS: A laparoscopic approach to ileal pouch formation was associated with a significant reduction in both major and minor complications compared with the traditional open approach. Given the high financial costs associated with complications arising from this procedure, this study provides support for the adoption of the laparoscopic approach in the formation of an IPAA.

Refining the Evaluation of Operating Room Performance

PURPOSE An accurate and consistent evaluation of resident operative performance is necessary but difficult to achieve. This study continues the examination of the Southern Illinois University (SIU) operative performance rating system (OPRS) by studying additional factors that may influence reliability, accuracy, and interpretability of results. METHODS OPRS evaluations of surgical residents by faculty at SIU, from 2001 to 2008, were analyzed for the most frequently rated procedures to determine (1) the elapsed time from the procedure until completion of rating, (2) the patterns in responses of procedure-specific and global surgical skills items, and (3) whether particular evaluating surgeons differed in their stringency of ratings of resident operative performance. RESULTS In all, 566 evaluations were analyzed, which consisted of open colectomy (n = 125), open inguinal hernia (n = 103), laparoscopic cholecystectomy (n = 199), and excisional biopsy (n = 139). The number of residents evaluated per training level (PGY) ranged from 88 to 161. The median time to completion of evaluations was 11 days, 9 hours. The quickest evaluation was 18 hours after assignment. Most were completed within 4.5 to 22 days. Procedure-specific and global scale scores resulted in similar rank-ordering of performances (single-measure intraclass correlation using the consistency model = 0.88; 95% confidence interval [CI] = 0.87-0.90) and similar absolute OPRS scores (single-measure intraclass correlation using the consistency model = 0.89; 95% CI, 0.87-0.90). Evaluating surgeons differed in stringency of ratings across procedures (average difference = 1.4 points of 5 possible points). Resident performance improved with increasing PGY level for all 4 procedures. CONCLUSIONS Substantial time elapses between performance in the operating room and the completion of the evaluation. This raises the question of whether surgeons remember the nuances of the procedure well enough to rate performance accurately. The item type used for rating does not affect the absolute rating assigned or the rank ordering of the performance. Differences in stringency of evaluators indicate the need for multiple resident performance observations by multiple surgeons. These findings are the foundation for an upcoming multi-institutional trial.

Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database.

Objective: To establish the relationship between operative approach (laparoscopic or open) and subsequent surgical infection (both incisional and organ space infection) postappendectomy, independent of potential confounding factors. Background: Although laparoscopic appendectomy has been associated with lower rates of incisional infections than an open approach, the relationship between laparoscopy and organ space infection (OSI) is not as clearly established. Methods: Cases of appendectomy were retrieved from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005 to 2008. Patient factors, operative variables, and the primary outcomes of incisional infections and OSIs were recorded. Factors associated with surgical infections were identified using logistic regression models. These models were then used to calculate probabilities of OSI in clinical vignettes demonstrating varying levels of infectious risk. Results: A total of 39,950 appendectomy cases were included of which 30,575 (77%) were performed laparoscopically. On multivariate analysis, laparoscopy was associated with a lower risk of incisional infection [odds ratio (OR) 0.37, 95% confidence interval (CI) 0.32–0.43] but with an increased risk of OSI after adjustment for confounding factors (OR 1.44, 95% CI 1.21–1.73). For a low-risk patient, probability of OSI was calculated to be 0.3% and 0.4%, respectively, for open versus laparoscopic appendectomy, whereas for a high-risk patient, probabilities were estimated at 8.9% and 12.3%, respectively. Conclusion: Laparoscopy was associated with a decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy.

Skills coaches as part of the educational team: A randomized controlled trial of teaching of a basic surgical skill in the laboratory setting

BACKGROUND The aim of this study was to compare the laboratory teaching of a basic technical skill by a nonphysician skills coach and a faculty surgeon. METHODS Medical students were randomized to instruction of skin suturing in the skills laboratory by a faculty surgeon or by a nonphysician skills coach. Testing of performance occurred at 3 time points. Other faculty surgeons, blinded to identities and training groups, rated performance. RESULTS Forty-nine students participated. Baseline fourth-year student mean scores showed no significant difference between training groups. Third-year and fourth-year student performance showed no difference between training groups on postintervention testing. Delayed testing also showed no difference in third-year student scores. CONCLUSIONS Training by either a nonsurgeon skills coach or a faculty surgeon resulted in no difference in performance on a basic surgical skill. This was true for students with and without prior experience and was also true after subsequent clinical experiences. Nonphysician coaches may ease the teaching burden of surgical faculty members while providing similar quality of instruction for trainees.

Improvement in Educational Effectiveness of Morbidity and Mortality Conferences with Structured Presentation and Analysis of Complications

PURPOSE Although morbidity and mortality (M & M) conferences are cornerstones of surgical teaching, they are not consistent in their educational quality. The current study examines the content and process of M & M presentations by surgical residents and hypothesizes that a structured format for these presentations can improve teaching and learning. METHODS The educational effectiveness of M & M conferences was assessed through the observation of case presentations, questionnaires to residents measuring learning from presentations, and an anonymous survey of residents regarding perceptions of the effectiveness of conferences. A structured presentation format was devised to address the deficits noted from these assessments and subsequently introduced to all residents and faculty. M & M conferences were then reassessed using the 3 methods. RESULTS Forty M & M presentations by surgical residents were observed before the implementation of the standardized format, and 35 presentations were observed after the changes. Observation of presentations noted significant changes in residents clearly presenting causes of complications and proposing strategies for practice change. Questionnaires of residents demonstrated improved ability to specify the causes of complications after implementation of the new format (mean rating, 4.56 vs 3.11, p < 0.05) as well as to identify specific ways to avoid the complication in the future (mean, 4.31 vs 3.42, p < 0.05). Online survey results also demonstrated improved resident perception of the specificity of content covered during M & M conferences as well as in their opinions regarding the discussion process. CONCLUSIONS A structured format for M & M presentations is a practical tool to help residents analyze complications systematically and identify steps for potential changes consistently in clinical practice. Such a format also leads to improved learning for other residents participating in these conferences. Without structured presentations, M & M conferences fail to deliver clear educational messages regarding surgical complications.

Prediction of postdischarge venous thromboembolism using a risk assessment model

OBJECTIVE The risk of postdischarge venous thromboembolism (VTE) (either deep vein or pulmonary embolism) is increasingly recognized yet the prescription of postdischarge thromboprophylaxis is inconsistent. There is a paucity of information to aid clinicians in identifying surgical patients who are at increased risk for postdischarge VTE. This study aimed to determine the incidence and risk factors associated with symptomatic postdischarge VTE and develop a risk score to identify patients who may benefit from extended duration thromboprophylaxis. METHODS This was a retrospective study. All nonorthopedic cases in which the patient was discharged alive without inpatient VTE were selected from the 2005-2009 National Surgical Quality Improvement Program database. A multivariate logistic regression was used to create a risk score for postdischarge VTE prediction. The dataset was split into two-thirds for risk score development and validated in the remaining one-third. RESULTS The overall incidence of early postdischarge VTE for 2005-2009 National Surgical Quality Improvement Program was 0.3%. The risk score stratified patients into low, moderate, and high risk for postdischarge VTE with the incidence based on the risk score ranging from 0.07% to 2.2%. The risk score had good predictive ability with c-statistic = 0.72 for model development and c-statistic = 0.71 in the validation dataset. Factors associated with postdischarge VTE on multivariate analysis included race, increasing age, steroid use, body mass index ≥30, malignancy, higher American Society of Anesthesiologists class, increasing operative time, length of postsurgical stay, and major postoperative complication. CONCLUSIONS This novel postdischarge VTE prediction score utilizes patient, operative, and early outcome factors to accurately identify patients at increased risk of a postdischarge thromboembolic event. The development of a patient- specific postdischarge VTE risk profile may help address the challenge of determining postdischarge prophylaxis requirements.

It’s the procedure not the patient: the operative approach is independently associated with an increased risk of complications after rectal prolapse repair

Aim  This study compares 30‐day outcomes following rectal prolapse repair, examining potential surgical and patient factors associated with perioperative complications.

The impact of operative approach in elective splenectomy: a multivariate analysis of outcomes from the NSQIP database.

Purpose: Laparoscopy is an increasingly prevalent choice for elective splenectomy but it carries an inconsistent documentation of complications. This study examines 30-day postoperative outcomes after open (OS) and laparoscopic (LS) splenectomy. Methods: Elective splenectomies were extracted from the National Surgical Quality Improvement Program database. Multivariate analysis determined factors associated with complications and an increased postoperative length of stay (LOS). Results: There were a total of 1583 splenectomies with 991 (63.0%) laparoscopic cases. On univariate analysis, the LS group had fewer major (10.6% vs. 18.8%, P<0.0001) and minor complications (2.6% vs. 7.1%, P<0.0001). Adjusting for baseline differences, LS was not associated with an increase in major complications [odds ratio (OR), 0.76; 95% confidence interval, 0.54-1.08; P=0.1255] but offered a decrease in minor complications (OR, 0.41; 95% confidence interval, 0.24-0.69; P=0.0010) coupled with a decrease in postoperative LOS of 1.89±0.30 days (P<0.0001) compared with OS. Conclusions: After accounting for comorbidities and intraoperative factors, laparoscopy remains a safe choice for elective splenectomy with fewer complications and shorter LOS.

The future of innovation and training in surgical oncology

This article addresses the current paradigms of surgical oncology training and the directions in which the training process may evolve over the course of the next decade. In doing so, the potential influences upon this evolution are discussed along with potential barriers associated with each of these factors. In particular, the topics include issues of specialty training with regard to new technologies and procedures, involvement of the surgeon as part of the multi-disciplinary team of oncologists, and the very real issue of burnout and career satisfaction associated with the profession of surgical oncology. Changes to the training of tomorrows cancer surgeons will need to involve each one of these factors in a comprehensive and efficient manner, in order to ensure the continued strength and growth of the field.