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Consequences of Increasing Complexity in Anorectal Surgery Performed at an Academic Center

Hiller, David J., M.D.1; Chadi, Sami A., M.D., M.Sc.2; Rosen, Lester, M.D.1; Wexner, Steven D., M.D., Ph.D. (Hon.)1

Diseases of the Colon & Rectum: March 2019 - Volume 62 - Issue 3 - p 343–347
doi: 10.1097/DCR.0000000000001204
Original Contributions: Anorectal
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BACKGROUND: Anorectal surgery encompasses a wide range of procedures with varying complexity. The Accreditation Council for Graduate Medical Education Review Committee for Colon and Rectal Surgery recommends minimum case numbers (60) for 1-year specialty trainees in 6 categories of anorectal surgery, with definitions for procedural complexity.

OBJECTIVE: The purpose of this study was to assess the scope of anorectal procedures and propose a stratification of procedures based on a consensus of levels of difficulty, as well as to identify a predictive charge cutoff suggestive of procedural complexity.

DESIGN: This was a retrospective review.

SETTINGS: The study was conducted at a tertiary academic center.

PATIENTS: Patients undergoing anorectal procedures between January 2011 and December 2014 identified by Current Procedural Terminology coding were entered into 6 categories. Codes were stratified as routine or complex based on an assessment of perioperative care and technical expertise required. Patients with an abdominal portion to any procedure were excluded.

MAIN OUTCOMES MEASURES: The study measured distribution of complexity in anorectal surgical procedures and procedural charge associated with differentiating routine from complex procedures.

RESULTS: Seven colorectal surgeons performed 2483 anorectal procedures (mean = 620 per year). Mean age was 48 ± 16 years. Forty six (64%) of 71 procedures were classified as routine and 25 (36%) of 71 as complex. Most disease processes had subsets with routine or complex procedures, whereas all of the procedures performed for fecal incontinence or advanced anorectal techniques were considered complex. Fistula procedures and transanal excisions were most heterogeneous, with a high procedural complexity rate (37% and 50%). After a procedural complexity rating, intraclass correlation by 6 surgeons was 0.70, demonstrating good correlation. Receiver operating curve assessments of consensus categorization according to billing codes revealed $553 as the optimal cutoff between routine and complex procedures.

LIMITATIONS: This was a single-institution retrospective review.

CONCLUSIONS: Colorectal residents may benefit from anorectal case stratification, because it serves as a dialogue for those interested in complex anorectal surgery during training. Surgeon categorization of procedures correlates well with a charge-based model of complexity. See Video Abstract at

1 Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida

2 Department of Surgery, University Health Network and the University of Toronto, Toronto, Ontario, Canada

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: None reported.

Financial Disclosure: No relevant financial disclosures.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Los Angeles, CA, April 30 to May 4, 2016.

Correspondence: Steven D. Wexner, M.D., Ph.D. (Hon.), Cleveland Clinic Florida, Department of Colorectal Surgery, 2950 Cleveland Clinic Blvd, Weston, FL 33331. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons