Faculty Bibliography

OBJECTIVES/OBJECTIVE:To examine whether the administration of mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) was associated with reduced surgical site infections (SSIs), which in turn leads to a reduction of non-SSI-related postoperative complications. BACKGROUND:Administration of MBP/OABP before elective colectomy reduces the incidence of SSI. We hypothesized that reduction of SSI is on causal pathway between the use of MBP/OABP and the reduction of other postoperative complications. METHODS:The study population consisted of all colectomy cases in the American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012 and 2013. Postoperative outcomes were compared based on the type of bowel preparation: none, MBP only, OABP only, and MBP plus OABP adjusting for other covariates. RESULTS:The cohort included 19,686 patients. Of these 5060 (25.7%) patients did not receive any form of bowel preparation, 8020 (40.7%) received MBP only, 641 (3.3%) received OABP only, and 5965 (30.3%) received MBP plus OABP. Patients who received MBP plus OABP had a lower incidence of superficial SSI, deep SSI, organ space SSI, any SSI, anastomotic leak, postoperative ileus, sepsis, readmission, and reoperation compared with patients who received neither (all P < 0.01). The reduction in SSI incidence was associated with a reduction in wound dehiscence, anastomotic leak, pneumonia, prolonged requirement of mechanical ventilator, sepsis, septic shock, readmission, and reoperation. CONCLUSIONS:Combined MBP plus OABP before elective colectomy was associated with reduced SSI, which ultimately was associated with a reduction in non-SSI-related complications.

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

BACKGROUND:The incidence of anal cancer in human immunodeficiency virus (HIV)-positive individuals is increasing, and how co-infection affects outcomes is not fully understood. This study sought to describe the current outcome disparities between anal cancer patients with and without HIV undergoing abdominoperineal resection (APR). METHODS:A retrospective review of all US patients diagnosed with anal squamous cell carcinoma, undergoing an APR, was performed. Cases were identified using a weighted derivative of the Healthcare Utilization Project's National Inpatient Sample (2000-2011). Patients greater than 60 years old were excluded after finding a skewed population distribution between those with and without HIV infection. Multivariable logistic regression and generalized linear modeling analysis examined factors associated with postoperative outcomes and cost. Perioperative complications, in-hospital mortality, length of hospital stay, and hospital costs were compared for those undergoing APR with and without HIV infection. RESULTS:A total of 1725 patients diagnosed with anal squamous cell cancer undergoing APR were identified, of whom 308 (17.9 %) were HIV-positive. HIV-positive patients were younger than HIV-negative patients undergoing APR for anal cancer (median age 47 years old versus 51 years old, p < 0.001) and were more likely to be male (95.1 versus 30.6 %, p < 0.001). Postoperative hemorrhage was more frequent in the HIV-positive group (5.1 versus 1.5 %, p = 0.05). Mortality was low in both groups (0 % in HIV-positive versus 1.49 % in HIV-negative, p = 0.355), and length of stay (LOS) (10+ days; 75th percentile of patient data) was similar (36.9 % with HIV versus 29.8 % without HIV, p = 0.262). Greater hospitalization costs were associated with patients who experienced a complication. However, there was no difference in hospitalization costs seen between HIV-positive and HIV-negative patients (p = 0.66). CONCLUSIONS:HIV status is not associated with worse postoperative recovery after APR for anal cancer as measured by length of stay or hospitalization cost. Further study may support APRs to be used more aggressively in HIV-positive patients with anal cancer.

BACKGROUND:Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing. OBJECTIVES/OBJECTIVE:To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma. METHODS:A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy. RESULTS:115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14). CONCLUSIONS:Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.

IMPORTANCE:The Bundled Payments for Care Improvement Initiative was proposed by the Centers for Medicare and Medicaid Services to obtain and reward a greater value of care. Still in its infancy, little is known regarding the potential effects of the Bundled Payments for Care Improvement Initiative on hospital payments and net margins. OBJECTIVE:To investigate the potential effects of the Bundled Payments for Care Improvement Initiative on net margins among Medicare patients undergoing colectomy at a tertiary care hospital. DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional retrospective analysis conducted in October 2015. Medicare enrollees undergoing an elective colectomy at a large tertiary care hospital between January 1, 2009, and December 31, 2013, were identified using diagnosis-related group and International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. MAIN OUTCOMES AND MEASURES:Multivariable linear regression analysis was performed to calculate risk-adjusted, diagnosis-related group-specific hospital costs and payments for each patient. Net margins were calculated as the difference between total hospital costs and total payments received. RESULTS:A total of 821 Medicare enrollees underwent an elective colectomy and met inclusion criteria. The median age of patients was 69 years (interquartile range [IQR], 65-74 years), with 51.3% being female. Postoperative complications were observed among 27.5% of patients (n = 226) and the median length of stay was 8 days (IQR, 5-14 days). The median risk-adjusted cost among all patients was $24 951 (IQR, $16 197-$38 922). Risk-adjusted costs were higher among patients who developed a postoperative complication ($42 537 [IQR, $28 918-$72 316] vs $22 829 [IQR, $14 820-$26 150]; P < .001) and among patients with an observed to expected length of stay greater than 1 ($36 826 [IQR, $24 951-$65 016] vs $16 197 [IQR, $14 182-$23 998]; P < .001). The median payment under the fee-for-service structure was $29 603 (IQR, $17 742-$44 819), resulting in an overall net margin of $3177 (IQR, -$1692 to $10 773), with 33.7% of patients (n = 277) contributing to an overall negative margin. In contrast, under the bundled payment paradigm, the net margin per patient was $3442 (IQR, -$9311 to $8203), with 41.7% of patients (n = 342) contributing to a net negative margin. CONCLUSIONS AND RELEVANCE:Postoperative complications, length of stay, and total hospital costs were strongly associated with hospital costs. Payments under the bundled payments system were lower and the proportion of patients contributing to a net negative margin increased. Further study is warranted to define the effect of bundled payments on quality of care and hospital finances.

Risk-adjusted institutional transfusion rates are not currently available on a national level. A surrogate means of benchmarking transfusion practices to use for internal quality improvement was studied. Blood utilization was prospectively studied among all colorectal surgery patients at the study institution (July 2010-November 2012), and these data were benchmarked with transfusion data from the National Surgical Quality Improvement Program (NSQIP) database by hospital type and size. Using NSQIP, the study institution's colorectal surgery transfusion rate was 16.3% (150/920 cases), which was slightly higher than the 14.3% national mean transfusion rate (12 191/85 507 cases; P = .08). When broken down by hospital type and size, the study hospital had a similar rate of blood transfusion compared with academic hospitals (P = .35) but a significantly higher rate than community hospitals, regardless of patient volume (P = .03). Benchmarking blood utilization compared with similar-type hospitals using NSQIP may be a surrogate method to assess adherence to evidence-based transfusion guidelines and identify areas for structured quality improvement initiatives.

IMPORTANCE/OBJECTIVE:High-resolution anoscopy (HRA) is becoming increasingly advocated as a method of screening for anal dysplasia in high-risk patients. OBJECTIVE:To describe, through HRA findings, the association between patient symptomatology and anal dysplasia among patients at high risk for anal dysplasia. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Univariable and multivariable analyses were conducted of data from a prospectively maintained HRA database on all patients undergoing HRA with biopsy from November 1, 2011, to March 13, 2014, at a tertiary care HRA clinic. Data included demographics, medical history and comorbidities, HIV status and related measures (CD4 cell counts, HIV viral load, and use of highly active antiretroviral therapy), sexual orientation (when available), patient symptoms at initial presentation, physical examination findings, anal Papanicolaou (Pap) smear findings. MAIN OUTCOMES AND MEASURES/METHODS:High-resolution anoscopy diagnosis of high- vs low-grade dysplasia or no dysplasia. RESULTS:One hundred sixty-one HRA biopsy specimens (mean [SEM], 1.77 [0.11] biopsy specimens per patient) were obtained from 91 patients (mean [SEM] age, 45.7 [1.2] years; 61 men [67%]; 47 black patients [52%]; and 70 human immunodeficiency virus-positive patients [77%]). Twenty-seven patients (30%) had high-grade dysplasia, 26 had low-grade dysplasia (29%), and 38 had no dysplasia (42%). The majority of patients (63 [69%]) were asymptomatic (anal pain, 11 [12%]; bleeding, 14 [15%]; and pruritus, 10 [11%]). Forty-one patients (45%) presented with anal pain (odds ratio, 5.25; 95% CI, 1.44-21.82; P = .02), and patients with either high- or low-grade dysplasia were more likely to present with anal lesions on physical examination compared with patients without dysplasia (odds ratio, 4.34; 95% CI, 1.78-11.20; P = .002). Multivariable analysis suggested that anal pain was independently associated with high-grade dysplasia (odds ratio, 6.42; 95% CI, 1.18-43.3; P = .03). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Anal dysplasia is a silent disease that is frequently asymptomatic. However, patients with anal pain, anal lesions, and other high-risk factors are at increased risk of having high-grade anal dysplasia. These patients may benefit from routine screening with HRA.

PURPOSE/OBJECTIVE:Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. As obesity is becoming more epidemic in surgical patients, the aim of this study was to investigate if obesity increases complication rates following IPAA. METHODS:This study was conducted as a retrospective review of patients undergoing IPAA between January 1990 and April 2011. Patients were categorized by body mass index (BMI): BMI < 30 (non-obese) and BMI ≥ 30 (obese). Preoperative patient demographics, operative variables, and postoperative complications were recorded through chart review. The primary outcome studied was cumulative complication rate. RESULTS:A total of 103 non-obese and 75 obese patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80 % vs. 64%, p = 0.03), primarily accounted for by increased pouch-related complications (61% vs. 26%, p < 0.01). In particular, obese patients had more anastomotic/pouch strictures (27% vs. 6%, p < 0.01), inflammatory pouch complications (17 % vs. 4%, p < 0.01) and pouch fistulas (12% vs. 3%, p = 0.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR] = 2.86, p = 0.01) for pouch-related complications. CONCLUSIONS:Obesity is associated with an increased risk of overall and pouch-related complications following IPAA. Obese patients should be counseled preoperatively about these risks accordingly.