This Viewpoint advocates for action to ensure that the use of surgical artificial intelligence adheres to the same ethical principles of safety and transparency that guide surgical practice.

BACKGROUND:Lower limb compartment syndrome (LLCS) is a rare but potentially devastating complication of prolonged lithotomy positioning in colorectal surgery. The mechanisms appear to be related to prolonged pressure on muscle compartments, leading to hypoperfusion followed by reperfusion injury. This study aims to identify the incidence of LLCS after colorectal surgery and identify associated risk factors to inform evidence-based prevention strategies. STUDY DESIGN:Adults from the American College of Surgeons NSQIP (2006 to 2022) undergoing colorectal surgery were included. The primary outcome was postoperative compartment syndrome leading to fasciotomy. Patients with concurrent vascular procedures and embolism diagnoses were excluded. The association between operative time and fasciotomy was assessed using multivariable logistic regression. RESULTS:Among 773,981 patients, 35 underwent fasciotomy within 2 days of their colorectal procedure. The median operative time was 388 minutes (interquartile range 165 to 539) for the fasciotomy group and 162 minutes (interquartile range 113 to 320) for the nonfasciotomy group (p < 0.001). Adjusted multivariable analysis demonstrated a time-response relationship between operative time and fasciotomy as the odds of fasciotomy were 3.5-fold higher after 3 to 5 hours and increased with longer operative time. In addition, other factors associated with fasciotomy included age younger than 50 years, American Society of Anesthesiologists class IV to V, and preoperative transfusion. CONCLUSIONS:Providers should exercise caution when operating on younger patients in lithotomy positions with an operative time more than 3 to 5 hours, as prolonged operative time is associated with an increased risk of fasciotomy. Improving awareness alongside the development of guidelines for routine intraoperative lower extremity assessment can facilitate early recognition and prevention of LLCS.

Given the unremitting obstacles to effectively screen for and treat ovarian cancer (OC), prevention is a necessary countermeasure. The recent discovery of the fallopian tube as the origin of the most common and deadly type of OC, high grade serous cancer (HGSC), makes prevention through salpingectomy possible (Madsen et al., 2015). Opportunistic salpingectomy (OS) is the practice of removing the post-reproductive fallopian tubes at the time of other intraperitoneal surgery, or for sterilization in lieu of tubal ligation, to decrease OC risk (Falconer et al., 2015). The safety, effectiveness, and reach of OS as a primary prevention strategy depends on the knowledge mobilization of a standard surgical approach for surgeons (Hanley et al., 2017; Morelli et al., 2013). Resources for accomplishing this knowledge mobilization activity are needed. We therefore aim to create a peer-reviewed, publicly available surgical instructional video that facilitates standardization of the practice of salpingectomy for the purpose of OC prevention.Content creation was generated by a team of surgeon stakeholders, medical illustrators, instructional designers, and health education specialists. Expert gynecologic surgeons were filmed performing salpingectomy in order to build a video library. Accurate illustration and editing of live video footage was executed to support surgeons in visualizing key anatomic landmarks to ensure safe and complete fallopian tube excision. Review of eligibility criteria, fundamentals of preoperative counseling, and strategic and technical points were prioritized. This endeavor is strictly educational, with no commercial benefit. Publicly available, peer-reviewed surgical education tools will help us collaborate to safely and equitably expand OS within and beyond the current scope of surgical practice.

Background: Total neoadjuvant therapy (TNT) is an accepted approach for the management of locally advanced rectal cancer (LARC) and is associated with a decreased risk of development of metastatic disease compared to standard neoadjuvant therapy. However, questions remain regarding surgical outcomes and local control in patients who proceed to surgery, particularly when radiation is given first in the neoadjuvant sequence. We report on our institution's experience with patients who underwent short-course radiation therapy, consolidation chemotherapy, and surgery. Methods: We retrospectively reviewed surgical specimen outcomes, postoperative complications, and local/pelvic control in a large cohort of patients with LARC who underwent neoadjuvant therapy incorporating upfront short-course radiation therapy followed by consolidation chemotherapy. Results: In our cohort of 83 patients who proceeded to surgery, a complete/near-complete mesorectal specimen was achieved in 90 % of patients. This outcome was not associated with the time interval from completion of radiation to surgery. Postoperative complications were acceptably low. Local control at two years was 93.4 % for all patients- 97.6 % for those with low-risk disease and 90.4 % for high-risk disease. Conclusion: Upfront short-course radiation therapy and consolidation chemotherapy is an effective treatment course. Extended interval from completion of short-course radiation therapy did not impact surgical specimen quality.

BACKGROUND: Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%. OBJECTIVE: This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation. DESIGN: Perioperative interventions were administered to patients who underwent ileostomy creation. SETTINGS: A single tertiary care academic center. PATIENTS: Eighty patients participated in this program from February 2020 to January 2021. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program. RESULTS: Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission (p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission (p = 0.38). LIMITATIONS: This study is limited by its small sample size (N = 80). CONCLUSIONS: The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894. DISMINUCIÓN DE LA READMISIÓN DESPUÉS DE LA CREACIÓN DE UNA ILEOSTOMÍA MEDIANTE UN PROGRAMA DE MEJORA DE LA CALIDAD PERIOPERATORIA ANTECEDENTES: La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%. OBJETIVO: Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía. DISEÑO: Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía. AJUSTE: Se trataba de un único centro académico de atención terciaria. PACIENTES: Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021. PRINCIPALES MEDIDAS DE RESULTADO: Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad. RESULTADOS: Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38). LIMITACIONES: Este estudio está limitado por su pequeño tamaño de muestra (n = 80). CONCLUSIONES: El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894. (Traducción—Dr Yolanda Colorado)

There has been a noted reluctance to offer laparoscopic surgery to Crohn’s Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn’s Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open. Crohn’s Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012–2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity. Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94–1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98–1.46, P = 0.074), when compared to an open approach. Among Crohn’s Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn’s Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.

BACKGROUND: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals. OBJECTIVE: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections. DESIGN: We performed a single-institution retrospective, nonrandomized, preintervention (2013–2014) and postintervention (2015–2017) analysis of hospital costs. SETTING: This study was conducted at an academic medical center. PATIENTS: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected. MAIN OUTCOME MEASURES: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses. RESULTS: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285–$28,658) compared to $21,896 ($17,477–$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286–$21,858) compared to $18,444 ($15,506–$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001). LIMITATIONS: This is a single-center study with a pre- and postintervention design. CONCLUSIONS: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS ANTECEDENTES: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales. OBJETIVO: El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon. DISEÑO: Realizamos un análisis retrospectivo, no aleatorio, previo (2013–2014) y posterior a la intervención (2015–2017) de los costos hospitalarios de una sola institución. AJUSTES: Centro médico académico. PACIENTES: Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades). PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos. RESULTADOS: El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285– $28,658) en comparación con $21,896 ($17,477– $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286– $21,858) en comparación con $18,444 ($15,506–$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001). LIMITACIONES: Este es un estudio de un solo centro con un diseño previo y posterior a la intervención. CONCLUSIONES: El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción—Dr. Gonzalo Hagerman)

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As healthcare expenditures rise, payers and providers have increasingly recognized the importance of measuring and improving value. Surgical care accounts for a significant percentage of total healthcare expenditures in the United States, and efforts to improve value globally must take into account the unique challenges and opportunities specific to elective surgical care. This situation makes it essential that surgeons have a thorough understanding of surgical value, its measurement, improvement, and incentivization efforts predicated on it. Toward that end, this review (1) explores the fundamental concept of value in healthcare, particularly as applied to surgery, (2) surveys the challenges in measuring surgical cost and quality, (3) describes the framework of value improvement, (4) identifies selected tools to help surgeons improve the value of care provided, and (5) discusses the increasing role that value-based competition is likely to play in the American healthcare industry. This review contains 5 figures, 3 tables, and 56 references. Key Words: healthcare costs, quality improvement, surgery, surgical value, value, value-based competition, value improvement

Background. Acute kidney injury (AKI) after major cardiac operations is a potentially avoidable complication associated with increased morbidity, death, and costly long-term treatment. The financial impact of AKI at the population level has not been well defined. We sought to determine the incremental index hospital cost associated with the development of AKI. Methods. All patients undergoing coronary artery bypass grafting (CABG) or valve replacement operations, or both (clinical classification software codes 43 and 44), between 2008 and 2011 were identified from the Nationwide Inpatient Sample. AKI was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes (584.xx); patients with chronic renal failure were excluded. Mean total index hospitalization costs were compared between patients with and without AKI. Results. At the population level, 1,078,036 individuals underwent major cardiac procedures from 2008 to 2011, with AKI developing in 105,648 (9.8%). Specifically, AKI developed in 8.0% of CABG, 11.4% of valve replacement, and 17.0% of CABG plus valve replacement patients (p < 0.001). Death was more common among patients with AKI vs those without (13.9% vs 1.3%, p < 0.001). Mean total index hospitalization cost was $77,178 for patients with AKI vs $ 38,820 for those without (p < 0.001). At the national level, the overall incremental annual index hospitalization cost associated with AKI was $ 1.01 billion. Conclusions. AKI developed in 1 in every 10 patients nationwide after a cardiac operation. Achieving a 10% reduction in AKI in this population would likely result in an annual savings of approximately $ 100,000,000 in index-hospital costs alone. Support for research on mechanisms to detect impending damage and prevent AKI may lead to reduced patient morbidity and death and to substantial health care cost savings. (C) 2018 by The Society of Thoracic Surgeons

Emergency General Surgery ( EGS ) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS . Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.

Background: Studies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates. Methods: Using VA data, we examined Pearson correlations between hospital-level VTE imaging rates and risk-adjusted PSI-12 rates and post-discharge VTE rates. To determine the robustness of findings, we conducted several sensitivity analyses. Results: Hospital imaging rates were positively correlated with both PSI-12 (r = 0.24, p = 0.01) and post-discharge VTE rates (r = 0.16, p = 0.09). Sensitivity analyses yielded similar findings. Conclusions: Like the prior VA study, we found no evidence of PSI-12-related surveillance bias. Given the use of PSI-12 in nationwide measurement, these findings warrant replication using similar methods in the non-VA setting. (C) 2018 Elsevier Inc. All rights reserved.

BACKGROUND:Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients.OBJECTIVE:To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC.DESIGN, SETTING, AND PARTICIPANTS:Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program.INTERVENTION:Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts.RESULTS AND LIMITATIONS:Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown.CONCLUSIONS:Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention.PATIENT SUMMARY:This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Background Current guidelines recommend in-hospital venous thromboembolism prophylaxis for many patients and extended/outpatient prophylaxis in high-risk patients undergoing abdomino-pelvic surgery for cancer. Despite these guidelines, extended venous thromboembolism prophylaxis is not used uniformly at all institutions. This study aimed to evaluate the impact of postdischarge prophylaxis practices at two academic medical centers on the rate of postdischarge venous thromboembolism. Methods We retrospectively analyzed data from the Brigham and Women’s Hospital and the Johns Hopkins Hospital’s American College of Surgeons, National Surgical Quality Improvement Program registries from 1 August 2014 to 30 June 2015. Brigham and Women’s Hospital patients received four weeks supply of extended/outpatient venous thromboembolism prophylaxis, while Johns Hopkins Hospital patients did not. We determined the proportion of patients in each cohort that developed venous thromboembolism within 30 days of surgery. Results Four hundred and eighty-nine patients underwent abdominal surgery for cancer and inflammatory bowel disease; 181 (37.0%) patients from Brigham and Women’s Hospital and 308 (63.0%) patients from Johns Hopkins Hospital. Fourteen patients developed postoperative venous thromboembolism. Seven patients developed in-hospital venous thromboembolism and seven developed venous thromboembolism postdischarge. All postdischarge venous thromboembolism occurred in the Johns Hopkins group, and this difference was statistically significant (p = 0.0498). There was no difference in postdischarge bleeding rates between the groups. Conclusions Extended prophylaxis likely prevents postdischarge venous thromboembolism after major abdominal surgery without an increased risk of bleeding.