Richard C. Thirlby

Virginia Mason Medical Center, Seattle, Washington, United States

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Publications (76)437.6 Total impact

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    ABSTRACT: Venous thromboembolism (VTE) is an important complication of colorectal surgery, but its incidence is unclear in the era of VTE prophylaxis. To describe the incidence of and risk factors associated with thromboembolic complications and contemporary VTE prophylaxis patterns following colorectal surgery. Prospective data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP) linked to a statewide hospital discharge database. At 52 Washington State SCOAP hospitals, participants included consecutive patients undergoing colorectal surgery between January 1, 2006, and December 31, 2011. Venous thromboembolism complications in-hospital and up to 90 days after surgery. Among 16 120 patients (mean age, 61.4 years; 54.5% female), the use of perioperative and in-hospital VTE chemoprophylaxis increased significantly from 31.6% to 86.4% and from 59.6% to 91.4%, respectively, by 2011 (P < .001 for trend for both). Overall, 10.6% (1399 of 13 230) were discharged on a chemoprophylaxis regimen. The incidence of VTE was 2.2% (360 of 16 120). Patients undergoing abdominal operations had higher rates of 90-day VTE compared with patients having pelvic operations (2.5% [246 of 9702] vs 1.8% [114 of 6413], P = .001). Those having an operation for cancer had a similar incidence of 90-day VTE compared with those having an operation for nonmalignant processes (2.1% [128 of 6213] vs 2.3% [232 of 9902], P = .24). On adjusted analysis, older age, nonelective surgery, history of VTE, and operations for inflammatory disease were associated with increased risk of 90-day VTE (P < .05 for all). There was no significant decrease in VTE over time. Venous thromboembolism rates are low and largely unchanged despite increases in perioperative and postoperative prophylaxis. These data should be considered in developing future guidelines.
    JAMA SURGERY 06/2015; DOI:10.1001/jamasurg.2015.1057 · 4.30 Impact Factor
  • Aaron J. Small, Richard C. Thirlby, Andrew S. Ross
    Gastrointestinal Endoscopy 05/2015; 81(5):AB177. DOI:10.1016/j.gie.2015.03.1937 · 4.90 Impact Factor
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    ABSTRACT: To determine the impact of elective colectomy on emergency diverticulitis surgery at the population level. Current recommendations suggest avoiding elective colon resection for uncomplicated diverticulitis because of uncertain effectiveness at reducing recurrence and emergency surgery. The influence of these recommendations on use of elective colectomy or rates of emergency surgery remains undetermined. A retrospective cohort study using a statewide hospital discharge database identified all patients admitted for diverticulitis in Washington State (1987-2012). Sex- and age-adjusted rates (standardized to the 2000 state census) of admissions, elective and emergency/urgent surgical and percutaneous interventions for diverticulitis were calculated and temporal changes assessed. A total of 84,313 patients (mean age 63.3 years and 58.9% female) were hospitalized for diverticulitis (72.2% emergent/urgent). Elective colectomy increased from 7.9 to 17.2 per 100,000 people (P < 0.001), rising fastest since 2000. Emergency/urgent colectomy increased from 7.1 to 10.2 per 100,000 (P < 0.001), nonelective percutaneous interventions increased from 0.1 to 3.7 per 100,000 (P = 0.04) and the frequency of emergency/urgent admissions (with or without a resection) increased from 34.0 to 85.0 per 100,000 (P < 0.001). In 2012, 47.5% of elective resections were performed laparoscopically compared to 17.5% in 2008 (when the code was introduced). The elective colectomy rate for diverticulitis more than doubled, without a decrease in emergency surgery, percutaneous interventions, or admissions for diverticulitis. This may reflect changes in thresholds for elective surgery and/or an increase in the frequency or severity of the disease. These trends do not support the practice of elective colectomy to prevent emergency surgery.
    Annals of Surgery 01/2015; DOI:10.1097/SLA.0000000000001053 · 7.19 Impact Factor
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    ABSTRACT: FOXP3 regulatory T cell prevent inflammation but are paradoxically increased in ulcerative colitis (UC). Local T-cell activation has been hypothesized to account for increased FOXP3 expression in colon lamina propria (LP) T cells. To see if human FOXP3 LP T cells are an activated fraction of otherwise FOXP3 effector T cells and explore their clonal diversity in health and disease, we deep sequenced clonally unique T-cell receptor hypervariable regions of FOXP3 and FOXP3CD4 T-cell subpopulations from inflamed versus noninflamed colon LP or mesenteric lymph nodes of patients with or without UC. The clonal diversity of each LP T-cell population was not different between patients with versus without UC. Repertoire overlap was only seen between a minority of FOXP3 and FOXP3 cells, including recently activated CD38 cells and Th17-like CD161 effector T cells, but this repertoire overlap was not different between patients with versus without UC and was no larger than the overlap between Helios and Helios FOXP3 cells. Thus, at steady state, only a minority of FOXP3, and particularly Helios, T cells share a T-cell receptor sequence with FOXP3 effector populations in the colon LP, even in UC, revealing distinct clonal origins for LP regulatory T cell and effector T cells in humans.
    Inflammatory Bowel Diseases 11/2014; DOI:10.1097/MIB.0000000000000242 · 5.48 Impact Factor
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    ABSTRACT: To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines.
  • Journal of the American College of Surgeons 09/2014; 219(3):S20. DOI:10.1016/j.jamcollsurg.2014.07.036 · 4.45 Impact Factor
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    ABSTRACT: Objective: Our goal was to perform a comparative effectiveness study of intravenous (IV)-only versus IV + enteral contrast in computed tomographic (CT) scans performed for patients undergoing appendectomy across a diverse group of hospitals. Background: Small randomized trials from tertiary centers suggest that en- teral contrast does not improve diagnostic performance of CT for suspected appendicitis, but generalizability has not been demonstrated. Eliminating en- teral contrast may improve efficiency, patient comfort, and safety. Methods: We analyzed data for adult patients who underwent nonelective appendectomy at 56 hospitals over a 2-year period. Data were obtained directly from patient charts by trained abstractors. Multivariate logistic regression was utilized to adjust for potential confounding. The main outcome measure was concordance between final radiology interpretation and final pathology report. Results: A total of 9047 adults underwent appendectomy and 8089 (89.4%) underwent CT, 54.1% of these with IV contrast only and 28.5% with IV + enteral contrast. Pathology findings correlated with radiographic findings in 90.0% of patients who received IV + enteral contrast and 90.4% of patients scanned with IV contrast alone. Hospitals were categorized as rural or ur- ban and by their teaching status. Regardless of hospital type, there was no difference in concordance between IV-only and IV + enteral contrast. After adjusting for age, sex, comorbid conditions, weight, hospital type, and perfo- ration, odds ratio of concordance for IV + enteral contrast versus IV contrast alone was 0.95 (95% CI: 0.72–1.25). Conclusions: Enteral contrast does not improve CT evaluation of appendicitis in patients undergoing appendectomy. These broadly generalizable results from a diverse group of hospitals suggest that enteral contrast can be eliminated in CT scans for suspected appendicitis.
    Annals of Surgery 07/2014; 260(2):311-316. DOI:10.1097/SLA.0000000000000272 · 7.19 Impact Factor
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    ABSTRACT: In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy.
    07/2014; 149(8). DOI:10.1001/jamasurg.2014.77
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    ABSTRACT: IMPORTANCE Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations. OBJECTIVE To report 3-year change in weight and select health parameters after common bariatric surgical procedures. DESIGN AND SETTING The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery. MAIN OUTCOMES AND MEASURES Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed. RESULTS At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%). CONCLUSIONS AND RELEVANCE Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes. TRIAL REGISTRATION Identifier: NCT00465829.
    JAMA The Journal of the American Medical Association 11/2013; 310(22). DOI:10.1001/jama.2013.280928 · 30.39 Impact Factor
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    Surgery for Obesity and Related Diseases 11/2013; 9(6):926–935. DOI:10.1016/j.soard.2013.01.023 · 4.94 Impact Factor
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    ABSTRACT: Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.
    The American surgeon 03/2013; 79(3):279-83. · 0.92 Impact Factor
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    ABSTRACT: Background Surgical site infections (SSI) are an important source of morbidity and mortality. Chlorhexidine in isopropyl alcohol is effective in preventing central venous-catheter associated infections, but its effectiveness in reducing SSI in clean-contaminated procedures is uncertain. Surgical studies to date have had contradictory results. We aimed to further evaluate the relationship of commonly used antiseptic agents and SSI, and to determine if isopropyl alcohol had a unique effect. Study Design We performed a prospective cohort analysis to evaluate the relationship of commonly used skin antiseptic agents and SSI for patients undergoing mostly clean-contaminated surgery from January 2011 through June 2012. Multivariate regression modeling predicted expected rates of SSI. Risk adjusted event rates (RAERs) of SSI were compared across groups using proportionality testing. Results Among 7,669 patients the rate of SSI was 4.6%. The RAERs were 0.85 (p=0.28) for chlorhexidine (CHG), 1.10 (p=0.06) for chlorhexidine in isopropyl alcohol (CHG+IPA), 0.98 (p=0.96) for povidone-iodine (PVI) and 0.93 (p=0.51) for iodine-povacrylex in isopropyl alcohol (IPC+IPA). The RAERs were 0.91 (p=0.39) for the non-IPA group and 1.10 (p=0.07) for the IPA group. Among elective colorectal patients the RAERs were 0.90 (p=0.48) for CHG, 1.04 (p=0.67) for CHG+IPA, 1.04 (p=0.85) for PVI and 1.00 (p=0.99) for IPC+IPA. Conclusions For clean-contaminated surgical cases, this large-scale state cohort study does not demonstrate superiority of any commonly-used skin antiseptic agent in reducing the risk of SSI, nor does it find any unique effect of isopropyl alcohol. These results do not support the use of more expensive skin preparation agents.
    Journal of the American College of Surgeons 01/2013; 218(3). DOI:10.1016/j.jamcollsurg.2013.11.018 · 4.45 Impact Factor
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    ABSTRACT: BACKGROUND: FOXP3+ regulatory T cells (Tregs) play a critical role in maintaining intestinal immune homeostasis. Although a defect in Tregs has therefore been proposed to underlie the mucosal immune dysregulation of ulcerative colitis (UC), there is paradoxically an increased number of Tregs in the mucosa of patients with UC. To address this paradox, we set out to characterize mucosal Tregs from patients with versus without UC in terms of function, phenotype, and clonality.METHODS: Lamina propria (LP) cells isolated from the surgically resected colons of patients with versus without UC were stained with panels of antibodies recognizing intracellular and extracellular markers of Treg differentiation, activation, and inhibitory function. Of CD4+ cells, FOXP3+ cells were sorted into Helios+ ("natural") and Helios- ("induced") Tregs, while FOXP3- cells were sorted into CD161+ (Th17-containing) and CD161- (Th17-depleted) cells for TCR sequencing. Also, live colonic LP cells were sorted into CD4+/CD25+/CD127- Tregs, as well as CD161+ or CD161- CD4+/CD25- effector T cells, plus CD11c+ HLA-DR+ monocytoid cells for functional analyses analyzing the suppressive function of LP Tregs, the sensitivity of LP effector T cells thereto, and the effect of LP monocytoid cells upon Treg function in vitro.RESULTS: LP FOXP3+ Tregs were more common in the mucosa of UC patients, but expressed Helios at a similar frequency, when compared to controls. Both Helios+ and Helios- Tregs expressed similar amounts of the putative suppressive molecules CD25, CD39, PD-1, CTLA-4 and TIGIT in UC patients as in controls, revealing no defect in inhibitory receptor expression in IBD. Both Helios+ and Helios- Tregs from UC patients showed at least as much expression of activation markers as Tregs from controls, indicating no selective lack of Treg stimulation in IBD. The clonal diversity of Tregs from UC patients and controls was similar, with a similar degree of overlap between Treg subsets and effector populations. In functional assays, Tregs from UC patients were at least as potent suppressors of proliferation as those of controls. Likewise, effector T cells from UC patients showed no insensitivity to suppression by Tregs, and the inhibitory function of Tregs was not compromised by the presence of CD11c+ cells from UC patients.CONCLUSIONS: We find no defects in FOXP3+ Tregs to account for their paradoxical plentitude in UC. Their Helios expression and unique clonal repertoire argue against them being simply effector T cells locally induced to express FOXP3 by activation in a TGF-beta-rich environment in UC. They demonstrate no defect in activation nor inhibitory receptor expression ex vivo to compromise their suppressive function, and indeed demonstrate suppressive function in in vitro Treg assays that is at least as good as Tregs from patients without UC. Their inability to suppress inflammation in vivo also does not appear to be due effector T cells resisting their suppressive activity, not as a result of signals from CD11c+ antigen presenting cells.(C) Crohn's & Colitis Foundation of America, Inc.
    Inflammatory Bowel Diseases 01/2013; 19:S99-S100. DOI:10.1097/01.MIB.0000438927.73382.01 · 5.48 Impact Factor
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    ABSTRACT: The interview process is a pivotal, differentiating component of the residency match. Our bias is toward a working interview, producing better fulfillment of the needs of both parties, and a more informed match selection for the candidates and program. We describe a "candidate-centered" approach for integrating applicant interviews into our daily work schedule. Applicants are informed upon accepting the interview of the working interview model. Our program offers 33 interview days over a 12-week period. A maximum of 5 applicants are hosted per day. Applicants are assigned to 1 of our general, thoracic, vascular, or plastic surgery teams. The interview day begins with the applicant changing into scrubs, attending a morning conference, and taking part in a program overview by a Chief Resident. Applicants join their host team where 4-8 hours are spent observing the operative team, on rounds and sharing lunch. The faculty and senior residents are responsible for interviewing and evaluating applicants though the Electronic Residency Application Service. A total of 13 surgeons are involved in the interview process resulting in broad-based evaluations. Each surgeon interviewed between 3 and 12 applicants. Faculty rate this interview approach highly because it allows them to maintain a rigorous operative schedule while interacting with applicants. Current residents are engaged in welcoming applicants to view the program. Faculty and residents believe cooperating in a real world manner aids their assessment of the applicant. Applicants routinely provide positive feedback, relaying this approach is informative, transparent, and should be the "standard." Applicants believe they are presented a realistic view of the program. Ultimately, this candidate-centered process may be attributable to our resident cohort who exhibit high satisfaction, excellent resident morale, and very low dropout rate. We present a candidate-centered, working interview approach used in the selection of general surgery residents. While it may require more resources than the traditional approach, it harbors advantages for the applicant and the program.
    Journal of Surgical Education 11/2012; 69(6):802-6. DOI:10.1016/j.jsurg.2012.06.004 · 1.39 Impact Factor
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    ABSTRACT: BACKGROUND AND OBJECTIVES:: Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis, safely reducing negative appendectomies (NAs); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. METHODS:: Data were collected prospectively for consecutive appendectomy patients (age > 15 years) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiological, operative, and pathological reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. RESULTS:: Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, it was 15.4% (P < 0.001). This association was consistent for men (3% vs 10%, P < 0.001) and for women of reproductive age (6.9% vs 24.7%, P < 0.001). In a multivariate model adjusted for age, sex, and white blood cell count, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95% CI: 3.0-4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. CONCLUSIONS:: Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change.
    Annals of surgery 09/2012; 256(4):586-594. DOI:10.1097/SLA.0b013e31826a9602 · 7.19 Impact Factor
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    ABSTRACT: Forkhead box P3 (FOXP3)+ regulatory T cells (Tregs) are critical for controlling inflammation in the gastrointestinal tract. There is a paradoxical increase of mucosal FOXP3+ T cells in patients with inflammatory bowel disease (IBD). These FOXP3+ cells were recently shown to include interleukin (IL)-17A-producing cells in Crohn's disease, resembling Th17 cells implicated in autoimmune diseases. FOXP3 inhibits IL-17A production, but a naturally occurring splice variant of FOXP3 lacking exon 2 (Δexon2) cannot. We hypothesized that IBD patients preferentially express the Δexon2 variant of FOXP3 so the paradoxically increased mucosal Tregs in IBD could represent cells expressing only Δexon2. We used antibodies and primers that can distinguish between the full-length and Δexon2 splice variant of FOXP3 to evaluate expression of these isoforms in human intestinal tissue by immunohistochemistry and quantitative polymerase chain reaction (PCR), respectively. No difference in the expression pattern of Δexon2 relative to full-length FOXP3 was seen in ulcerative colitis or Crohn's disease versus non-IBD controls. By immunofluorescence microscopy and flow cytometry, we also did not find individual cells which expressed FOXP3 protein exclusively in the Δexon2 isoform in either IBD or control tissue. FOXP3+ mucosal CD4+ T cells from both IBD and control specimens were able to make IL-17A in vitro after phorbol myristate acetate (PMA) and ionomycin stimulation, but these cells did not preferentially express Δexon2. Our data do not support the hypothesis that selective expression of FOXP3 in the Δexon2 isoform accounts for the inability of copious FOXP3+ T cells to inhibit inflammation or IL-17 expression in IBD.
    Digestive Diseases and Sciences 06/2012; 57(11):2846-55. DOI:10.1007/s10620-012-2292-3 · 2.55 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (ie, death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from the 4th quarter of 2005 through 4th quarter of 2010. Of the 9,705 patients undergoing elective colorectal operations (mean age 60.6 ± 15.6 years; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 4th quarter of 2005 to 41.6% in 4th quarter of 2010 (trend during study period, p < 0.001). After adjustment (for age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size, and urban vs rural location), the risk of transfusions (odds ratio [OR] = 0.52; 95% CI, 0.39-0.7), wound infections (OR = 0.45; 95% CI, 0.34-0.61), and composite of adverse events (OR = 0.58; 95% CI, 0.43-0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a substantial increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, an 80.4% increase) and, in particular, the number of resections for noncancer diagnoses and right-sided pathology. The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery.
    Journal of the American College of Surgeons 04/2012; 214(6):909-18.e1. DOI:10.1016/j.jamcollsurg.2012.03.010 · 4.45 Impact Factor
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    ABSTRACT: To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. Observational, prospectively designed cohort study. Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.
    Archives of surgery (Chicago, Ill.: 1960) 04/2012; 147(4):345-51. DOI:10.1001/archsurg.2012.12 · 4.30 Impact Factor
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    ABSTRACT: Postoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function. A retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution. The time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002). These data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function.
    American journal of surgery 03/2012; 203(5):644-8. DOI:10.1016/j.amjsurg.2011.12.007 · 2.41 Impact Factor
  • Richard C Thirlby
    Archives of surgery (Chicago, Ill.: 1960) 03/2012; 147(3):234-5. DOI:10.1001/archsurg.2011.1413 · 4.30 Impact Factor

Publication Stats

2k Citations
437.60 Total Impact Points


  • 1992–2015
    • Virginia Mason Medical Center
      • Department of General, Thoracic and Vascular Surgery
      Seattle, Washington, United States
  • 2009
    • Trinity Washington University
      Washington, Washington, D.C., United States