Faculty Bibliography

BACKGROUND:Patients with severe, complicated Clostridium difficile infection (CDI) may ultimately require a colectomy. Although associated with high morbidity and mortality, a total colectomy has been the mainstay of surgical treatment. However, small studies have suggested partial colectomy may provide equivalent outcomes. We compared the outcomes of partial and total colectomy for CDI in a nationwide database. STUDY DESIGN/METHODS:We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). Patients with a primary diagnosis of Clostridium difficile colitis from 2007 to 2015, who underwent a total abdominal or partial colectomy, were analyzed. Postoperative mortality rate, complications, and length of stay were evaluated. Logistic regression controlling for patient and clinical factors evaluated the impact of type of operation performed. RESULTS:There were 733 colectomies for CDI, of which 151 (20.6%) were partial colectomies. Patients with a partial colectomy had a slightly higher 30-day mortality rate (37.1%) compared with total abdominal colectomy patients (34.7%, p = 0.58). However, logistic regression controlling for patient factors demonstrated no statistically significant difference for partial colectomy in 30-day mortality (odds ratio [OR] 1.21, 95% CI 0.76 to 1.96) or complication rate (OR 0.92, 95% CI 0.51 to 1.62) compared with total colectomy. There was no difference in days to surgery (4.6 partial vs 5.0 total, p = 0.70). Total abdominal colectomy trended toward a longer postoperative stay (18.0 vs 15.1 days for partial, p = 0.08). CONCLUSIONS:In a national database, a significant percentage of operations for CDI are partial colectomies. There were no significant differences found in mortality or complications between partial and total colectomy for severe complicated CDI.

IMPORTANCE:The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. OBJECTIVE:To investigate the association of the timing of colostomy reversal with operative outcomes. DESIGN, SETTING, AND PARTICIPANTS:This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. EXPOSURES:Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. MAIN OUTCOMES AND MEASURES:Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. RESULTS:In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. CONCLUSIONS AND RELEVANCE:Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.

PURPOSE:Predicting surgical risk is challenging. There is no curriculum to teach risk assessment to students. We hypothesize that a risk assessment curriculum will improve medical students' confidence in and familiarity with assessing risk, and help identify barriers to assessing risk. METHODS:Third year surgery clerkship students participated in a risk-assessment workshop. Students completed pre- and post-intervention surveys assessing their familiarity with models, and confidence in predicting postoperative complications. Additionally, they completed a retention survey 12-weeks following the session. RESULTS:Following the session, confidence in predicting post-operative morbidity and mortality improved from <1% to 21.9% and 19.05% respectively. The majority of students continued to feel more confident mortality 12-weeks following the session. Not seeing attendings/residents use the calculator was a significant barrier to use. CONCLUSIONS:This novel risk assessment curriculum improved student confidence towards assessing risk up to three months following the session. Additionally, this study highlights that barriers exist to using risk assessment tools clinically.

BACKGROUND:Prophylactic placement of ureteral stents is performed during open colectomy to aid in ureteral identification and to enhance detection of injury. The effects of this practice in laparoscopic colectomy are unknown. This study compares outcomes of patients undergoing laparoscopic colectomy with and without prophylactic ureteral stenting. METHODS:A retrospective cohort study at a tertiary academic medical center was performed. The primary outcome measure was the incidence of ureteral injury. Secondary outcomes evaluated included mortality, length of stay, procedural duration, and new-onset urinary complication (hematuria, dysuria, and urinary tract infection). RESULTS:In 702 consecutive patients undergoing elective laparoscopic colectomy from 2013 to 2016, prophylactic stents were placed in 261 (37%) patients. Two ureteral injuries occurred (0.3%), both in patients who underwent ureteral stent placement (P = 0.07) and were found and repaired intraoperatively. There was no in-hospital mortality. When accounting for age-adjusted Charlson comorbidity score, procedural indication, gender, BMI, and extent of resection, no difference in hospital length of stay (P = 0.79) was noted comparing patients with and without stenting. However, stent placement prolonged operating time (P = 0.03) and increased the risk of new-onset urinary complications (P = 0.04). CONCLUSIONS:In this study, ureteral injuries only occurred in those with stent placement. Prophylactic ureteral stents in laparoscopic colectomy are associated with increased operative time and urologic morbidity. Owing to the low prevalence of ureteral injury in the elective setting and the increased risk of urinary complications, use of prophylactic ureteral stenting should be highly selective.

BACKGROUND:Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject. METHODS:A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns. RESULTS:Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01). CONCLUSION:Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.

BACKGROUND:Percutaneous cholecystostomy (PC) is an initial alternative to laparoscopic cholecystectomy (LC) for complicated acute cholecystitis (AC). No studies have directly compared costs of index hospitalization and readmissions between PC and LC patients. METHODS:The Nationwide Readmissions Database was queried for patients undergoing PC or LC for AC from 2013 through 2014. Primary outcomes including length of stay, and index and total hospital costs at 30- and 60-days were evaluated after 1:1 propensity score matching for patient and hospital characteristics. RESULTS:PC patients had increased index hospital length of stay: 6 days vs 5 days (p < 0.01). Index admission cost was cheaper for PC ($12,839 vs $13,345, p = 0.028). Total cost, including readmissions, was significantly increased in PC patients: 30-days (LC: $13,947, PC: $14,592, p = 0.029) and 60-days (LC: $14,280, PC: $16,518, p < 0.0001). CONCLUSIONS:PC patients were more frequently readmitted, had longer hospital stays, and increased hospital costs compared to those undergoing LC.

BACKGROUND:High-risk patients undergoing cholecystectomy may experience increased morbidity and mortality. Percutaneous cholecystostomy (PC) has been utilized as a treatment option for acute cholecystitis in this cohort. Little is known about risk factors for readmission following PC. MATERIALS AND METHODS:Patients who had PC from 2013 to 2014 were identified from the National Readmission Database by the Healthcare Cost and Utilization Project. A 30-d readmission was defined as a subsequent admission within 30 d following the first admission discharge date. Multivariate logistic regression models using stepwise selection were employed to select significant predictive variables for subsequent readmission. RESULTS:Three thousand three hundred sixty-eight patients were identified with 698 (20.7%) readmissions during the study period. Of the readmitted patients, 79 (2.35%) had two readmissions and six patients (0.19%) had three or more readmissions within 30 d of their index procedure. In addition, alcohol use (odds ratios [OR] 1.58, confidence intervals [CI] 1.10-2.29), uncomplicated diabetes (OR 1.21, CI 1.00-1.47), congestive heart failure (OR 1.28, CI 1.03-2.44), depression (OR 1.42, CI 1.08-1.86), and metastatic cancer (OR 1.65, CI 1.11-2.46) were significantly correlated with risk for readmission. Readmitted patients had longer hospital stays (OR 1.38 CI 1.09-1.74, length of stay >8 d). CONCLUSIONS:A significant proportion of patients are readmitted within 30 d following PC. These patients may benefit from increase care coordination starting at their index admission. Studies are needed to determine patient selection for upfront cholecystectomy.

The traditional apprenticeship model of research mentorship, where residents pursue research projects directed by attending surgeons, may be ill-suited to optimize research innovation, productivity, and leadership experience. This is particularly true in an era of ever mounting demands of academic attending surgeons, easier availability of powerful clinical databases, and more residents beginning training with prior research experience and advanced degrees. To help makeup the gaps of traditional research mentorship, we propose a complementary peer-focused, "sideways mentorship" approach. This model revolves around a consortium of residents who develop their own research ideas, and obtain feedback and technical input from fellow residents. Such a model provides trainees more opportunities to explore their own ideas, become exposed to a wider range of disciplines, share technical knowledge and prior experience, and practice being mentors themselves. We believe sideways mentoring model can be successful in this changing research era, and is a valuable addition to the traditional research model and encourage educational programs to support efforts in establishing resident-run research collaborative.

OBJECTIVE:Medical students' abilities to predict postoperative complications and death are unknown. We hypothesize that medical students will lack confidence in determining surgical risk and will significantly overestimate surgical risk for post-operative morbidities and mortality. DESIGN/METHODS:Participants were invited to participate in an electronic, anonymous survey to assess their ability to predict surgical risk. The survey presented 7 complex clinical scenarios representative of a diverse general surgery practice. Participants were asked to assess the likelihood of different morbidities and mortality on a 0-100% scale, and predictions were compared to the ACS NSQIP risk calculator. SETTING/METHODS:Yale School of Medicine, New Haven, Connecticut; Tertiary medical center PARTICIPANTS: Third year medical students on their surgery clerkship as well as general surgery residents were invited to participate. RESULTS:Most students were not confident about predicting postoperative complications (83.3%) or mortality (70.8%). Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly overestimated postoperative morbidities and mortality. Estimates varied significantly, with wide 95% confidence intervals. Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals. CONCLUSIONS:Medical students overestimate morbidity and mortality following surgery in complex patients. Additionally, they lack confidence in their ability to predict surgical complications. A formal curriculum for risk prediction is needed for medical students.