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  1. 1. WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor June 2008 THE BEST THIS MONTH’S UPDATES SURGICAL Elements of Contemporary Public reporting programs related to other surgical procedures gener- THINKING Practice 3 Benchmarking Surgical ally rely on administrative data. The most widely available source of surgical outcomes data comes from A New Publisher for ACS Outcomes proprietary rating firms. Surgery Emily V. A. Finlayson, MD, MS, Wiley W. Souba, MD, ScD, FACS and John D. Birkmeyer, MD, Public Use Administrative FACS Ohio State University College of Databases University of Michigan Health ather than relying on outside Medicine DOI 10.2310/7800.2008.NCjun System R analysis, surgeons can obtain administrative data and do it DOI 10.2310/7800.SECPC03 he American College of Surgeons T recently entered into a long-term agreement with BC Decker Inc as the Public reporting programs, public use administrative databases, and themselves. For example, surgeons can obtain data from the Nation- wide Inpatient Sample, a database new publisher of ACS Surgery. Brian clinical registries all offer surgical containing information from Decker and the editors are very outcomes data to benchmark hospital and even surgeon-specific approximately 8 million hospital interested in continuing to elevate the performance. admissions annually. high quality of ACS Surgery and Administrative data have many making this a win-win relationship nterest about surgical outcomes is through the sharing of ideas and materials and joint promotion of the I growing. Patients want to make informed decisions about where and limitations for benchmarking outcomes, but the most important College and ACS Surgery. We want to limitations relate to problems with from whom to receive surgical care, accuracy, completeness, and clinical see ACS Surgery serve as a resource to and public and private payers want precision of coding. enhance the quality of surgical information about surgical perfor- practice and to increase membership mance for their value-based pur- in the American College of Surgeons. The ongoing evolution of ACS chasing initiatives. Surgery offers many advantages and continued on page 2 opportunities for its readers. As a Public Reporting Programs current subscriber, you should know he most readily available source that ACS Surgery was designed to be innovative and cutting edge. Our T of surgical outcomes data is Internet-based public reporting In This Issue commitment to you is to continue this programs. Currently, those based on The Best Surgical Thinking tradition. We will expand and A New Publisher for ACS Surgery 1 strengthen our efforts to integrate and clinical data are limited to cardiac surgery. Some states administer Elements of Contemporary Practice communicate principles and guidelines 3 Benchmarking Surgical Outcomes 1 for effective surgical practice in longitudinal clinical registries and 1 Basic Surgical and Perioperative cooperation with the College to assure regularly release information on Considerations subscribers that important new risk-adjusted mortality rates for 1 Prevention of Postoperative studies, therapies, and procedures are coronary artery bypass surgery. All Infection 3 systematically incorporated into ACS states release hospital-specific 6 Vascular System Surgery as rapidly as possible. performance data, but only some 12 Aortoiliac Reconstruction 4 continued on page 2 report surgeon-specific information.
  2. 2. 2 What’s New in ACS Surgery • June 2008 THE BEST SURGICAL THINKING continued from page 1 Owned and published by BC Decker Inc Of course, one of the key strengths it, how soon will it be outdated?” of ACS Surgery, the expertise of its Certainly, traditional textbooks are EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH editorial board members and authors, viewed by many as “an endangered FOUNDING EDITOR: will continue to be our anchoring species” with the ease of storage, orga- Douglas W. Wilmore, MD, FACS, Boston foundation. Other features that have nization, and retrieval of information EDITORIAL BOARD: established this text as an expert worldwide via the Internet. On the Mitchell P. Fink, md, facs, Pittsburgh Gregory J. Jurkovich, md, facs, Seattle Larry R. Kaiser, reference will also remain unchanged, other hand, medical publishing far md, facs, Philadelphia William H. Pearce, md, including our authoritative approach, surpasses the capacity of individuals to facs, Chicago John H. Pemberton, md, facs, Rochester, MN Nathaniel J. Soper, md, facs, renowned illustration style, and read, digest, and remember current Chicago subscriber services such as monthly information. There is a greater need COUNCIL OF FOUNDING EDITORS: updates, as well as our convenient and than ever for surgeons and other Murray F. Brennan, md, facs, New York economical continuing medical practitioners to have current, well- Laurence Y. Cheung, md, facs, Kansas City Alden H. Harken, md, facs, San Francisco education (CME) program. written, reliable information in a James W. Holcroft, md, facs, Sacramento The monthly updates of the text, the format that makes it easy to use. At Jonathan L. Meakins, md, dsc, facs, Oxford monthly newsletter, What’s New in ACS Surgery, we promise to do our PUBLISHER: President, Brian C. Decker ACS Surgery, and the monthly CME best to keep our succinctly written Vice President, Sales, Rochelle J. Decker program provide students, physicians comprehensive text current. We intend Vice President and Publisher, Liz Pope for it to provide you with the most Managing Editor, Susan Cooper in training, residency programs, and Manager, Special Sales, Jennifer Coates busy surgeons with an organized and current and up-to-date surgical Manager, Customer Care and Distribution, Marie thought available to help guide you Moore easy to grasp educational program to Rights and Permissions, Paula Mucci through difficult decisions and Director, Digital Publishing, David Love stay current. ACS Surgery serves as an procedures. Electronic Media Systems Analyst, Jeff Ferguson excellent pathway for maintenance of Senior Web/IT Developer, Faisal Shah ACS Surgery complements the certification, and many residency ACS Surgery: Principles & Practice (bound education materials and publications volume: ISBN 978-1-55009-399-5; CD-ROM: programs now subscribe to ACS of the College. Because we produce ISBN 978-1-55009-421-3; quarterly CD ROM: Surgery’s weekly curriculum program. ISSN 1538-3210; online: ISSN 1547-1616) is ACS Surgery on a continuing basis, owned and published by BC Decker Inc, 50 King There are many opportunities to like a journal, with a capacity to St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, advance these ideas and products update all materials at any time, ACS ON L8N 3K7, Canada, Web site: http://www. jointly. © 2008 BC Decker Inc. All rights Surgery is particularly valuable for reserved. No part of this issue may be reproduced Although we focus on content CME, for maintenance of certification, by any mechanical, photographic, or electronic development for the needs of practic- process or in the form of a phonographic and as part of a curriculum for recording, nor may it be stored in a retrieval ing general surgeons, ACS Surgery is graduate medical education. BC system, transmitted, or otherwise copied for of equal value for surgical specialists public or private use without written permission Decker Inc will uphold the traditions of the publisher. who need to keep up with topics in and excellence of ACS Surgery. In the Annual subscription rates in Canada and the general surgery. We also see a substan- months ahead, we will share with you USA: Quarterly CD-ROM: $209 (individual), tial opportunity to use ACS Surgery in new ideas involving design, referenc- $709 (institutional); Online: $189 (individual). Institutional Web site license pricing available on recruiting new international members ing, indexing, digital hosting, CME, request. Please e-mail to the College. and other features to increase the Separate shipping and handling apply. All prices subject to change without notice and quoted in Many have asked, “Is there a future value of being a subscriber to ACS US dollars. for medical textbooks?” or “If I buy Surgery. POSTMASTER: Send address changes to BC Decker Inc, PO Box 758, Lewiston, NY 14092- 0785. FOR ASSISTANCE WITH YOUR SUBSCRIPTION Please address all inquiries to Fulfillment Department, BC Decker Inc, P.O. Box 758, Lewiston, NY 14092- THIS MONTH’S UPDATES continued from page 1 0785, or call us at 905-522-7017 or 800-568-7281, or fax us at 905-522-7839 or 888-311-4987, or email us at For change of address, please provide both your new and your old addresses; be sure to notify us at least six weeks before you expect to move to avoid interruptions in your service. Clinical Registries A visible and powerful source of he ideal source of information for benchmarking information is YOUR FEEDBACK IS WELCOME T benchmarking surgical outcomes is prospective, clinical outcomes the National Surgical Quality Improvement Program (NSQIP). • E-mail: • Write: BC Decker Inc P.O. Box 620, LCD1 Hamilton, ON L8N 3K7 registries. Outcomes data from these Preoperative risk factors, intraopera- Canada sources are not reported publicly but tive variables, and 30-day postop- instead provide confidential feed- erative mortality and morbidity back on performance to hospitals outcomes for patients undergoing and surgeons. major surgery are submitted.
  3. 3. What’s New in ACS Surgery 3 Risk-adjusted morbidity and their own performance against these mortality results for each hospital are calculated semiannually and are benchmarks are not, particularly at the level of individual procedures. This Month’s CME reported as observed versus expect- ed ratios. Nonetheless, the NSQIP is When sample sizes are too small, it may be difficult to determine Chapters expensive to administer, and risk whether complication rates higher ACS Surgery offers CME in adjustment is not based on risk than the benchmark reflect genuine convenient online format. As factors specific to individual problems or simply chance. many as 60 AMA PRA Category procedures. Generalizability is another 1 credits can be earned at The Society of Thoracic Surgeons limitation. Owing to the individual any time during the year. The national database is the best source characteristics of each database, following chapters are available for benchmarking outcomes with different data sets yield different for CME credit this month: cardiac surgery. Its database mortality estimates. Although none 1 Basic Surgical and Perioperative includes clinical data on more than of these mortality estimates are Considerations 70% of all adult cardiothoracic “wrong,” surgeons must recognize 1 Prevention of Postoperative Infection operations performed annually in that risk estimates depend on the 6 Vascular System the United States. A major weakness is the lack of external auditing to composition of each database and 12 Aortoiliac Reconstruction ensure the accuracy and complete- may not be generalizable to their Elements of Contemporary Practice ness of outcomes data submitted by own practice. 3 Benchmarking Surgical Outcomes hospitals. The National Cancer Data Base (NCDB) tracks information related Basic Surgical and Perioperative only skin and subcutaneous tissue), to the treatment and outcome of cancer patients. About 1,400 Considerations deep incisional (involving deep soft tissue), and organ or space hospitals nationwide submit data to 1 Prevention of (involving anatomic areas that are the NCDB, which currently captures approximately 75% of incident Postoperative Infection opened or manipulated in the course of the procedure). cancer cases in the United States. Jonathan L. Meakins, MD, DSc, FACS Current risk assessments integrate Individuals at approved cancer the three determinants of infection: centers can access benchmark University of Oxford bacteria, local environment (including reports that summarize data from DOI 10.2310/7800.S01C01 surgeon factors), and systemic host the user’s own center and compari- defenses (patient factors). sons with state, regional, or national Surgical site infections have no data. However, data are not single cause, but can be systemati- externally audited to ensure cally reduced by stricter attention Role of Bacteria, Surgeon accuracy and completeness. to the bacteria that cause SSIs and Factors, and Patient Factors Currently, approximately 556 various environmental and host hospitals submit data to the Nation- in SSIs factors. al Trauma Data Bank, including ithout an infecting agent, no 70% of Level I– and 53% of Level II–designated trauma centers. Data H istorically, wound infection control depended on antiseptic W infection will result. Accord- ingly, most of what is known about submission is voluntary and not and aseptic techniques directed at bacteria is put to use in major externally audited. coping with the infecting organism. efforts directed at reducing their Two programs track outcomes In the 19th century and the early numbers by means of asepsis and with bariatric surgery. Clinical part of the 20th century, wound antisepsis. Endogenous bacteria are registries of the ACS Bariatric infections had devastating conse- a more important cause of SSI than Surgery Center Network Program quences and a measurable mortality. exogenous bacteria. In clean- and the Surgical Review Corpora- Even in the 1960s, before the correct contaminated, contaminated, and tion support hospital accreditation use of antibiotics and the advent of dirty-infected operations, the source and “centers of excellence” modern preoperative and postopera- and the amount of bacteria are designations in bariatric surgery. tive care, as many as one quarter of functions of the patient’s disease and the surgical ward patients might the specific organs being operated Limitations of Surgical have had wound complications. on. These infections have been reduced, The most obvious pathogenic Benchmarking but continue to have huge clinical bacteria in surgical patients are ll surgical benchmarks have A common limitations. The first relates to sample size. Although the and financial implications. The Centers for Disease Control gram-positive cocci (e.g., Staphylo- coccus aureus and streptococci). and Prevention uses the term S. aureus—in particular, MRSA—is benchmarks are usually based on surgical site infection (SSI) to take a major cause of SSI. The preopera- large numbers and are thus statisti- into consideration the operative site tive hospital stay also contributes to cally robust, the outcomes of as a whole. SSIs can be classified as wound infection rates. The usual hospitals and surgeons assessing superficial incisional (involving explanation is that either more
  4. 4. 4 What’s New in ACS Surgery • June 2008 endogenous bacteria are present or understanding of the steps necessary extent of testing is tailored to the commensal flora is replaced by to reduce SSIs overall: level of cardiac risk. hospital flora. • Keeping the bacterial Most of the local factors that contamination as low as Operative Techniques for make a surgical site favorable to possible via asepsis and bacteria are under the surgeon’s Aortoiliac Reconstruction antisepsis, preoperative prepara- lthough localized aortoiliac control, and the reach extends beyond good hand-washing tion of patient and surgeon, and antibiotic prophylaxis. A endarterectomy is less commonly performed today than it once was, it practices. For example, the use of • Maintaining local factors in drains that a surgeon chooses varies such a way that they can remains useful for a subgroup of widely and is very subjective. Using prevent the lodgment of bacteria patients with focal aortic bifurcation a closed suction drain reduces the and thereby provide a locally disease. The classic candidate has potential for contamination and unreceptive environment. minimal disease of the infrarenal infection. Also, in most studies, abdominal aorta and the external • Maintaining systemic responses contamination increases with the iliac arteries, but a severely diseased at such a level that they can con- and narrowed aortic bifurcation. duration of the operation. Nonethe- trol the bacteria that become Iliofemoral bypass, already an less, it is only expeditious operation established. uncommon procedure, has now that is appropriate, not speed. largely been supplanted by advances Finally, the use of electrocautery in percutaneous endoluminal devices has been associated with an 6 Vascular System techniques. Nevertheless, it is still increase in the incidence of superfi- used and is worth knowing. One cial SSIs unless used properly. 12 Aortoiliac Reconstruction limitation is that aortoiliac occlusive The human systemic response is Mark K. Eskandari, MD, FACS disease typically causes diffuse aortic designed to control and eradicate and bilateral iliac artery narrowing. infection, but can be overwhelmed Northwestern University Feinberg School of Medicine Iliofemoral bypass is most suitable by certain factors. Patients at risk for those rare patients who have for wound infection are those DOI 10.2310/7800.S06C12 isolated unilateral external iliac with three or more concomitant artery disease. diagnoses, those undergoing a Surgeons can choose a revascu- Before the application of percuta- clean-contaminated or contaminated larization approach to ameliorate neous balloon angioplasty and abdominal procedure, and those aortoiliac occlusive disease. stenting, aortofemoral bypass undergoing any procedure expected ymptomatic aortoiliac occlusive grafting was the revascularization to last longer than 2 hours. Also increasing the risk of SSI are shock, S disease is the consequence of a diffuse atherosclerotic process operation of choice for patients with diffuse aortoiliac occlusive disease. advanced age, transfusion, and the exacerbated by smoking, hyperten- This operation is still favored by use of steroids and other immuno- sion, hypercholesterolemia, and many, and it yields excellent long- suppressive drugs, including term patency. diabetes. The resultant narrowing of chemotherapeutic agents. A thoracofemoral bypass is ideal the aorta and the iliac vessels for a small subgroup of patients, impairs circulation into the pelvis comprising (1) those with an Steps Necessary to Reduce and the lower extremities, causing occluded old aortofemoral bypass complaints such as impotence and SSIs claudication and even ulceration or graft, (2) those with a so-called lead- ntibiotics have not always pipe calcified infrarenal aorta that is A prevented SSI successfully. Although surgeons were quick to gangrene. Choosing a surgical revascularization approach is based unusable as an inflow source, and (3) those with a so-called hostile on anatomic constraints and abdomen. Candidates must have appreciate the possibilities of comorbid conditions. adequate pulmonary reserve and be antibiotics, the efficacy of antibiotic Preoperatively, the physician able to tolerate a thoracotomy. prophylaxis was not accepted until should determine the extent of There is risk of paralysis. the following was unequivocally occlusive disease by measuring proved: lower extremity blood flow with • They are most effective when arterial waveforms and ankle- given before inoculation of brachial indices. An imaging study is bacteria. • They are ineffective if given 3 hours after inoculation. also required to guide revasculariza- tion. If an extra-anatomic bypass is Coming in July anticipated, ancillary tests, including 2 Head and Neck • They are of intermediate bilateral arm blood pressure 6 Parotidectomy effectiveness when given measurements and computed 9 Thyroid and Parathyroid Procedures between these times. tomography scans of the chest, 4 Thorax Significant advances in the control abdomen, or pelvis may be neces- 8 Minimally Invasive Esophageal of wound infection during the past sary. A standard cardiac risk Procedures several decades are linked to a better assessment is mandatory, and the
  5. 5. What’s New in ACS Surgery 5 Axillofemoral bypass is ideally disease has grown exponentially Overall Long-term suited to elderly patients who since its introduction in the 1990s. cannot tolerate an aortic operation. With regard to short-term results, Survival in Patients with The hemodynamic changes occur- patients experience less pain, recover Symptomatic Aortoiliac ring during the operation are more quickly, and regain function Disease minimal, and recovery from the earlier. egardless of which operation is three small incisions is generally quick. R performed, the subsequent outcome should be immediate relief A femorofemoral crossover bypass Complications of Aortoiliac is well suited to patients who have of presenting symptoms. Unfortu- Revascularization nately, overall long-term survival in unilateral complete occlusion or a leeding, distal embolization, graft diffusely diseased iliac system but have a relatively normal contralat- B thrombosis, and graft infection are associated with all revasculariza- patients with symptomatic aortoiliac occlusive disease is not improved by eral iliac system. It is performed operative management and is similarly to an axillofemoral bypass, tion procedures. Late graft infection, typically 10 to 15 years less than but without the axillary anastomo- recurrent disease, and pseudoaneu- that in a normal age-matched group. sis. rysm formation are known long- The most significant long-term cause In terms of endovascular therapy, term complications. Some complica- of death is atherosclerotic cardiac the use of percutaneous balloon tions are unique to one or more of disease, underscoring the impor- angioplasty and stenting for the the procedures but do not arise with tance of a thorough preoperative treatment of peripheral vascular the others. cardiac evaluation.