Colectomy for C difficile colitis carries a substantial mortality regardless of patient age and white blood cell count. Preoperative vasopressor requirement, mental status changes, and length of medical treatment significantly predict mortality.

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Background Anastomotic leak (AL) is a major source of morbidity in colorectal surgery and has become an area of interest in performance metrics. It is unclear whether AL is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if AL could serve as a valid quality metric in colorectal surgery by evaluating provider variation after adjusting for patient factors. Methods We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with AL. Hierarchical logistic regression was used to derive risk-adjusted rates of AL. Results Of 9,192 colorectal resections, 244 (2.7%) had a documented AL. The incidence of AL was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index > 30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count > 400×109/L), and urgent/emergent surgery were independently associated with AL (C-statistic = 0.75). After accounting for patient and procedural risk factors, there were five hospitals with a significantly greater incidence of postoperative AL. Conclusions This population-based study shows that risk factors for AL include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergent surgery; models including these factors predict most of the variation in AL rates. This study suggests that AL can serve as a valid metric that can identify opportunities for quality improvement.

Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

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