Can you lower your rate of return?From colorectal surgery complications

Complication Rate

30.5%of patients have complications2

Readmission Rate

11%of patients are readmitted within 30 days3

23%of patients are readmitted within 90 days4

Cost of Readmission

$9Kaverage readmission costs4

Ethicon’s goal is to help you to reduce complications and improve outcomes. Pre-clinical and other studies, professional education and other support

should be considered when making product selections.

Three of the leading causes of readmissions are:1 *

Surgical site infections > 7.6%

Bleeding complications > 6.9%

Anastomotic leaks > 3.9%

Colorectal OutcomesHigh rates of complications and readmissions are being increasingly scrutinized by surgeons and hospital administration.

* Other major causes are ileus, pneumonia & other respiratory complications, sepsis and fluid/electrolyte disorders.

ECHELON CIRCULAR™ Powered Stapler

Potential Ways to Lower Your Risk of a Staple Line Leak

61% fewer leaks at the staple line€

37% less movement at distal tip when firingβ

97% reduction in force to fire**

Tap here for more information on ECHELON CIRCULAR™ Powered Stapler

Anastomotic leaks:

11.9% occurrence in colorectal surgeries§2

2 – 3x additional health-care costs5

$16K - $19K average incremental cost2

2x longer length of hospital stay5

Anastomotic leaks are a dominant surgical concern due to their high mortality risk6

§ Frequency of anastomotic leaks* Benchtop testing in porcine stomach tissue.Mean tissue movement from after clamping on tissue to after firing ECHELON FLEX™ Powered Plus Stapler (PSEE60A) and ECHELON Reload with GST vs ENDO GIA™ ULTRA Handle (EGIAUSTND) and Endo GIA™ Reload with Tri-Staple™ Technology at 3.3 and 4.0mm tissue thicknesses (3.3mm: GST60T 0.642mm vs EGIA60AMT 4.806mm p<0.001; 4.0mm: GST60T 0.654mm vs EGIA60AXT 5.116mm p<0.001) † Benchtop testing in porcine colon ranging in width from 28mm to 36mm and in thickness from 1.5mm to 2.5mm, the GST 45mm Blue reload completely fired across in one firing 31% more often than Tri-Staple™ 45mm Purple reload, p=0.022. ‡ ECHELON™ GST System 60mm Blue and Green Reloads compared to Endo GIA with Tri-Staple™ Technology 60mm Purple Reloads evaluated via gross observations of firings in 1.5mm to 3.0mm thick animate porcine ileum. Additional testing demonstrated no significant performance difference between 60mm and 45mm reloads of the same brands. ¶ Benchtop testing on porcine rectum. Normalized mean tissue movement along the cut line from before clamping on tissue to after firing the CONTOUR® Curved Cutter Stapler (CS40G) vs ENDO GIA™ ULTRA Handle (EGIAUSTND) and Endo GIA™ Radial Reload with Tri-Staple™ Technology (EGIARADMT) on 2.1mm to 2.9mm thick tissue. 3.8mm (9.4%) vs 17.4mm (32.5%), p<0.001. € Benchtop testing in porcine tissue ≤30mmHg (26mmHg average pressure experienced during intra-operative leak test), comparing Ethicon CDH29P to Medtronic (Covidien) EEA2835 (p<0.001) and preclinical perfusion model, in which perfusion was not significantly different between devices. β Users firing in a porcine model, comparing Ethicon CDH29P to Medtronic Covidien EEA2835, p=0.003.¥ Benchtop testing on porcine colon, comparing Ethicon CDH29P to Medtronic Covidien EEA2835, p<0.001. ** Benchtop testing, comparing Ethicon CDH29P to Medtronic Covidien EEA2835, p=0.001.

33% reduction in compressive force on tissue¥

Claims compared to Medtronic DST Series™ EEA™ Stapler

CONTOUR®Curved Cutter Stapler

78% less tissue slippage during firing and more precise transection compared to Radial Reload with Tri-Staple™ Technology¶

Designed to be reloaded when needed to complete a single transection with multiple firingsClaims compared to Medtronic Endo GIA™ with Tri-Staple™ Technology

ECHELON FLEX™ GST System (Gripping Surface Technology)

4x less tissue slippage* More likely to transect the colon in a single firing†

More consistently captures all layers of tissue in the staple line‡

Claims compared to Medtronic Endo GIA™ with Tri-Staple™ Technology

FPO

FPO

ENSEAL® X1 Curved Jaw Tissue Sealer

More efficient than Ligasure™ Maryland§

In preclinical testing, 100% of vessels sealedβ

Achieved hemostasis on the first pass ¥

Maintained hemostasis during an elevated blood pressure challenge.¥

More tissue per bite with a 16% longer jaw and 40% wider jaw§

More secure grasping with 37% more grasping ability¶

More continuous shaft rotation with continuous 360° shaft rotation to easily access tissue€

The ENSEAL X1 Tissue Sealers offer more than LigaSureDesigned for use in open or laparoscopic surgical procedures

ENSEAL® X1 Large Jaw Tissue Sealer More secure than LigaSure Impact™*

41% less lateral thermal spread‡

With a larger distal electrode surface area†

With significiantly less bleeding at the distal tip in thick tissue: compared to LigaSure Impact™*

Tap here for more information on ENSEAL X1 Tissue Sealers

Potential Ways to Lower Your Risk of Bleeding Complications.

Perioperative Bleeding:

10.5% occurrence in colorectal surgeries2

$10K-$13K average incremental cost2

~$45K average cost to treat a hemorrhage in a cancer case7

* Preclinical test of distal tip bleeding (ENSEAL® X1 Large Jaw vs Impact-LF4318) in thick porcine mesentery base (p=0.001). (C2740). † C2166 ‡ Preclinical testing on porcine carotids (ENSEAL® vs Impact-LF4318) that measured mean max lateral thermal damage via histology (p=0.005). (C2618). § ENSEAL® X1 Curved Jaw Tissue Sealer can capture, seal and transect a longer length of tissue per single activation due to a16% (or 3.4mm) longer jaw (p < 0.001), a 40% (or 5.0mm) wider unbiased jaw aperture (p < 0.001) and a 19% (or 3.6mm) longer cut length (p < 0.001) compared to LigaSure™ Maryland (LF1937) (093774-180619) ¶ Grasping force measured as the maximum amount of force required to pull a thin strip of chamois, simulating a piece of tissue, from device jaws. Comparison of Enseal® X1 Curved Jaw to LigaSure™ Maryland (LF1937) (p<0.001). (C2720) € C2743 β n=38 seals for each device. ¥ Out of 38 vessels sealed in a preclinical study on porcine carotid arteries. During blood pressure challenge, blood pressure was increased to at least 200 mmHg for a minimum of 10 minutes to simulate a hypertensive crisis (C2734).

FPO

15.2% of colorectal surgeries will develop a SSI or BSI, which can lead to as many as 10 additional hospital days.2

The average incremental cost of an SSI is between $26K and $30K.2 SSIs increase the risk of other wound complications such

as 2.2x more likely to develop incisional hernia8 and

6x more likely to suffer wound dehiscence following abdominal surgery.9

Potential Ways to Lower Your Risk of Surgical Site Infections

Three clinical guidelines recommend triclosan-coated sutures: CDC, WHO, ACS-SiS† 11-13

MONOCRYL® Plus, PDS® Plus and Coated VICRYL® Plus Antibacterial Suture

Shown in vitro to inhibit colonization of the suture for 7 days or more, including bacteria commonly associated with SSIs14-17

DERMABOND® PRINEO® Skin Closure System

Provides a flexible microbial barrier with 99% protection

In vitro for 72 hours against common SSI-causing organisms‡ 10

Tap here for STRATAFIX™ Symmetric PDS™ PlusKnotless Tissue Control Device brochure

The only triclosan-coated antibacterial sutures in the US:

STRATAFIX™ Knotless Tissue Control Devices

The only barbed suture with antibacterial protection14, 15

Meta-analysis demonstrates 28% reduction in SSI risk with the use of triclosan-coated sutures18*

* 21 RCTs, 6462 patients, 95% CI: (14, 40%), P < 0.001. All triclosan-coated sutures in these RCTs were Ethicon Plus Antibacterial Sutures (Monocryl Plus, Vicryl Plus and PDS Plus. † The CDC, WHO, ACS-SIS Guidelines on reducing the risk of surgical site infections are general to triclosan-coated sutures and are not specific to any one brand. ‡ Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Pseudomonas aeruginosa.

FPO

FPO

National Professional Courses

Anastomotic Leak course

Complex Open Surgery course

OR Colorectal Team Training course

Advancements in Minimally Invasive Surgery — A Comprehensive Hands-on Symposium

Regional Professional Courses

Tailored lecture and in-lab training opportunities Course content varies bur can include open laparoscopic hand-held and robotic approaches,

procedural videos, webinars, teaching presentations and apps.

At Ethicon our goal is to provide products and support that help to reduce complications and improve patient outcomes.

Ethicon is the market leader in Colorectal Surgery*

Switch to Ethicon today.

Account Programs Hemostasis Optimization Program

Care Advantage Infection Risk Management Program Wound Closure Academy

Resident and Team Training Presentations• Reducing Anastomotic Leaks• Reducing Surgical Site Infections• Reducing Bleeding Complications

Ethicon Professional Education Courses and Account Programs

* DRG market data from July 2016 – June 2017, comparing market share in colorectal procedures.

For complete product details, refer to the relevant package inserts,with particular attention paid to the indications, contraindications,

warnings and precautions, and steps for use of the device.© 2018 Ethicon US, LLC. All rights reserved. 078801-181112

Ethicon Colorectal Solutions

REFERENCES:

1. Greenblatt, D. Y., Weber, S. M., Oʼconnor, E. S., Loconte, N. K., Liou, J., & Smith, M. A. (2010). Readmission After Colectomy for Cancer Predicts One-Year Mortality. Annals of Surgery, 251(4), 659-669.

2. Truven Comercial and Medicare, USA Colorectal Complication Rates 2010-2015.

3. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015; 313(5):483-495.

4. Wick EC, Shore AD, Hirose K, et al. Readmission rates and cost following colorectal surgery. Dis Colon Rectum. 2011; 54(12):1475-1479.

5. Schiff A, Brady BL, Ghosh SK, et al. Estimated Rate of Post-Operative Anastomotic Leak Following Colorectal Resection Surgery: A Systematic Review. Journal of Surgery and Surgical Research. 2016; 2(1):060-067.

6. Koianka T, Kevin M, Martin W, et al. Identifying Important Predictors for Anastomotic Leak After Colon and Rectal Resection. Annals of Surgery. 2013; 257:108.

7. Project Harlow Colorectal Multivariate Analyses. Ethicon Inc.

8. Israelsson, L. A., & Jonsson, T. (1996, February). Incisional hernia after midline laparotomy: A prospective study. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8639725

9. Van Ramshorst, G. H., Nieuwenhuizen, J., Hop, W. C., Arends, P., Boom, J., Jeekel, J., & Lange, J. F. (2010, January). Abdominal wound dehiscence in adults: Development and validation of a risk model. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19898894

10. Study Report for in vitro evaluation of microbial barrier properties of DERMABOND ProTape.

11. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. doi:10.1001/jamasurg.2017 .0904.

12. WHO Global Guidelines for the Prevention of Surgical Site Infection, 2016.

13. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2016; 224:59-74.

14. Ming X, Rothenburger S, Nichols MM. In vivo and in vitro antibacterial efficacy of PDS Plus (polidioxanone with triclosan) suture. Surg Infect (Larchmt). 2008; 9(4):451-457.

15. Ming X, Rothenburger S, Yang D. In vitro antibacterial efficacy of Monocryl Plus Antibacterial Suture (poligelcaprone 25 with triclosan). Surg Infect (Larchmt). 2007; 8(2):201-207.

16. Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antimicrobial evaluation of coated Vicryl Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect (Larchmt). 2002; 3 (suppl):S79-S87.

17. Storch ML, Rothenburger S, Jacinto G. Experimental Efficacy Study of Coated VICRYL Plus Antibacterial Suture in Guinea Pigs Challenged with Staphylococcus aureus. Surg Infect (Larchmt). 2004; 5(3):281-288.

18. de Jonge SW, Atema JJ, Solomkin JS, Boermeester MA. Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical site infection. Brit J Surg. 2017; ePub-DOI:10.1002/bjs.10445