BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN: This was a population-based, retrospective administrative analysis. SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year–old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146–$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682–$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583–$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548–$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739–$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study. LIMITATIONS: Inherent biases associated with administrative databases limited this study. CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at http://links.lww.com/DCR/A839.

PURPOSE: Perioperative ostomy education is essential for patients to develop skills and comfort with self-care at home with a new ostomy, but shortened hospital length of stay (LOS) reduces time for postoperative education for patients. This study explored the initial experiences and care needs of patients who have undergone creation of a new ostomy during their transition from hospital to home. DESIGN: Qualitative interpretive description using latent content analysis. SUBJECTS AND SETTING: Thirteen patients who had undergone an elective colorectal surgery involving creation of an ostomy were interviewed. Participants were 33 to 78 years of age, 54% were female, and 62% were undergoing ostomy creation for colorectal cancer operations. Eleven participants underwent temporary ileostomy creation, and 2 patients had permanent end colostomies created. METHODS: Interviews were conducted in person and audiotaped by study investigators within 4 to 6 weeks postoperatively. Audiotapes were transcribed verbatim by trained transcriptionists, and each transcript was reviewed in duplicate by study investigators. A latent content analysis method was used to determine the implied meaning in participants' experiences of having a new ostomy. RESULTS: The transition from hospital to home with a new ostomy was illustrated by 5 major themes: (1) Having an ostomy is a life-changing and bizarre experience; (2) Adjustment and adaptation occur through acceptance and self-reliance; (3) It's a hands-on thing: with the role of WOC nurse providing support in achieving independence; (4) Improved home care infrastructure is needed; and (5) Practical advice shared from experiential learning. CONCLUSION: Patients with new ostomies are motivated and able to cope with the ostomy and regain independence over a short period after surgery. Shorter LOS does not impede ostomy education so long as adequate home care and support group programs are available. Knowledge gained through this study will assist WOC nurses in managing patients' expectations and the planning and delivery of education to patients with newly created ostomies.

Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes Background: The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes.Methods: This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications.Results: One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect. Conclusion:In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.Contexte : Les Tokyo Guidelines, publiées en 2007, puis mises à jour en 2013 et en 2018, contiennent des recommandations sur le diagnostic et la prise en charge de la cholécystite aiguë. Nous avons évalué le respect de ces lignes directrices dans notre centre universitaire et son incidence sur les issues pour les patients.Méthodes : Ce document est une revue rétrospective de dossiers des patients atteints de cholécystite aiguë calculeuse qui ont subi une cholécystectomie dans notre établissement entre novembre 2013 et mars 2015. La gravité de la cholécystite a été établie de manière rétrospective si elle n'avait pas été documentée avant l'opération. Le respect des recommandations des Tokyo Guidelines concernant le recours à des antibiotiques et la durée de l'opération a été étudié. Nous avons comparé statistiquement les groupes de gravité de la cholécystite, et avons utilisé...

BACKGROUND:Optimal management of bile leaks (BLs) after severe liver injury is unknown. Study objectives were to define current practices in diagnosis and management of BL to determine which patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP). METHODS:American Association for the Surgery of Trauma grade ≥III liver injuries from 10 North American trauma centers were included in this retrospective study (February 2011 to January 2021). Groups were defined as patients who developed BL versus those who did not. Subgroup analysis of BL patients was performed by management strategy. Bivariate analysis compared demographics, clinical/injury data, and outcomes. Receiver operating characteristic curves were performed to investigate the relationship between bilious drain output and ERCP. RESULTS:A total of 2,225 patients with severe liver injury met the study criteria, with 108 BLs (5%). Bile leak patients had higher American Association for the Surgery of Trauma grade of liver injury ( p < 0.001) and were more likely to have been managed operatively from the outset (69% vs. 25%, p < 0.001). Bile leak was typically diagnosed on hospital day 6 [4-10] via surgical drain output (n = 37 [39%]) and computed tomography scan (n = 34 [36%]). On the BL diagnosis day, drain output was 270 [125-555] mL. Endoscopic retrograde cholangiopancreatography was the most frequent management strategy (n = 59 [55%]), although 32 patients (30%) were managed with external drains alone. Bile leak patients who underwent ERCP, surgery, or percutaneous transhepatic biliary drain had higher drain output than BL patients who were managed with external drains alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Receiver operating characteristic curve analysis of BL demonstrated moderate accuracy (area under the receiver operating characteristic curve, 0.636) for ERCP at a cutoff point of 390 mL of bilious output on the day of diagnosis. CONCLUSION:Patients with BL >300 to 400 mL were most likely to undergo ERCP, percutaneous transhepatic biliary drain, or surgical management.Once external drainage of BL has been established, we recommend ERCP be reserved for patients with BL >300 mL of daily output. Prospective multicenter examination will be required to validate these retrospective data.