Background Centralization of care to “centers of excellence” in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal ...cancer care in the United States. Methods The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥10 resections/year) and hospitals (≥25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints. Results Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48–0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21–0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time. Conclusion This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.
Background Evidence suggests that statins may decrease inflammation, airway hyperreactivity, and hypercoagulability while improving revascularization mediated by cholesterol-independent pathways. ...This study evaluated whether the preoperative use of statins is associated with decreased postoperative major noncardiac complications in noncardiac procedures. Study design This was a single-institution study of noncardiac operations performed from 2005 to 2010. The use of statins was identified from electronic medical records and merged with local National Surgical Quality Improvement Program data. Preoperative statin exposure was defined as statin use before operation, as documented by admission medication reconciliation and outpatient or pharmacy records. The primary end point was major noncardiac complications, and secondary end points included respiratory, infectious (sepsis and organ space infection) and complications of venous thromboembolism (VTE). Multivariable logistic regression was performed for each end point while we controlled for clinical covariates meeting P < .10 on bivariate analysis. Results Preoperative statin use was present in 10.5% ( n = 814) of 7,777 total cases. Procedure type included general operation ( n = 2,605, 33.5%), breast/endocrine ( n = 739, 9.5%), colorectal ( n = 1,533, 19.7%), hepatobiliary/pancreatic ( n = 397, 5.1%), orthopedic ( n = 205, 2.6%), skin/ear-nose- throat (145, 1.9%), thoracic ( n = 53, 0.7%), upper gastrointestinal ( n = 651, 8.4%), and vascular cases (1,449, 18.6%). On multivariable analysis, the use of statins was associated with decreased major, noncardiac complications (odds ratio OR 0.62, 95% confidence interval 95% CI 0.49–0.92, P < .001), respiratory complications (OR 0.63, 95% CI 0.50–0.79, P = .017), VTE (OR 0.41, 95% CI 0.18–0.98, P = .044), and infectious complications (OR 0.65, 95% CI 0.45–0.94, P = .023). Conclusion The preoperative use of statins is independently associated with decreased risk of major complications. This effect is likely driven by reduction in respiratory, VTE, and infectious complication rates. These results warrant future clinical trials to assess the perioperative benefit of statin use in noncardiac procedures.
Background Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases ...do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak. Methods The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010–2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks. Results Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001). Conclusion Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.
Abstract The treatment of anastomotic leaks remains primarily operative; however, recent advances in technology are changing the scope of non-operative interventions for managing this difficult ...complication. The authors sought to provide an evidence-based review of the non-operative treatment options for anastomotic leaks using both current guidelines and investigational modalities on the horizon. A search of MEDLINE, PubMed, and the Cochrane Database of relevant scientific papers and reviews was performed. Abstracts were reviewed to determine their scientific merit and relevance to non-operative treatment of anastomotic leaks. Recommendations and treatment algorithms were based on consensus conclusions of the data. A total of 87 articles were reviewed and analyzed for this article. Reoperation is the first-line therapy for many anastomotic leaks, but non-operative techniques are appropriate and effective for a subset of this population. Image-guided percutaneous drainage has changed the treatment paradigm for many patients with anastomotic leaks. Endoscopic drainage and stenting are in their infancy, and controlled trials are needed to prove their efficacy; however, the future of non-operative treatment appears promising.
