1. www.acssurgery.com
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 What’s New in ACS Surgery • June 2008 www.acssurgery.com
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. bcdecker.com. © 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
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THIS MONTH’S UPDATES
continued from page 1
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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: acssurgery@bcdecker.com
• 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. www.acssurgery.com

3. www.acssurgery.com 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 What’s New in ACS Surgery • June 2008 www.acssurgery.com
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. www.acssurgery.com 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.