Trends in hospital volume and operative mortality for high-risk surgery

Performance comparisons in major uro-oncological surgeries between the USA and Japan

OBJECTIVES

To elucidate the differences in clinical practice between the USA and Japan in major types of uro-oncological surgery by a head-to-head comparison of national databases in the two countries.

METHODS

We compared variations in surgical modality, length of stay, total charges, caseload centralization, transfusion incidence, and in-hospital mortality between the two countries for four major types of uro-oncological surgery (radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy) in 2011. Additionally, the chronological changes in surgical modalities were investigated for 2009-11. The national estimates were based on data from the Japanese Diagnosis Procedure Combination database and the US National Inpatient Sample.

RESULTS

For radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy, minimally-invasive surgery accounted for 24.2% versus 70.2%, 0% versus 14.0%, 50.7% versus 30.7% and 50.2% versus 30.5%, respectively, in Japan versus the USA in 2011. Although minimally-invasive surgery has become increasingly frequent in both countries, the major procedures were robot-assisted surgery in the USA and laparoscopic surgery in Japan. The USA was generally characterized by a slightly younger age at operation, far higher hospital volume, a shorter length of stay, higher charges and less use of transfusion than Japan.

CONCLUSIONS

The findings suggest substantial differences between the USA and Japan regarding clinical practices in uro-oncological surgery. Standing at the beginning of robotic surgery era in Japan, the precise recognition of these differences will aid a proper understanding of clinical practices.

Centralization of esophagectomy: how far should we go?

BACKGROUND

This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

METHODS

Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

RESULTS

Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93).

CONCLUSIONS

Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.

Evolution of standardized clinical pathways: refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer

BACKGROUND

The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience.

STUDY DESIGN

All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012).

RESULTS

Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively.

CONCLUSIONS

The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.

Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity

OBJECTIVE

The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy (PD) from nasojejunal tube (NJT) feeding to early oral feeding improved clinical outcomes.

METHODS

An observational cohort study was performed in 102 consecutive patients undergoing PD. In period 1 (n = 51, historical controls), the routine postoperative feeding strategy was NJT feeding. This was changed to a protocol of early oral feeding with on-demand NJT feeding in period 2 (n = 51, consecutive prospective cohort). The primary outcome was time to resumption of adequate oral intake.

RESULTS

The baseline characteristics of study subjects in both periods were comparable. In period 1, 98% (n = 50) of patients received NJT feeding, whereas in period 2, 53% (n = 27) of patients did so [for delayed gastric empting (DGE) (n = 20) or preoperative malnutrition (n = 7)]. The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 (P = 0.015), and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 (P = 0.015). Overall, there were no differences in the incidences of complications of Clavien-Dindo Grade III or higher, DGE, pancreatic fistula, postoperative haemorrhage and mortality between the two periods.

CONCLUSIONS

The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity.

Designing a safe and sustainable pediatric neurosurgical practice: the English experience

The 2001 Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 stated that there must be standards for hospitals as a whole and that hospitals, which do not meet these standards, should not be able to offer services within the National Health Service (NHS). In 2013, agreed standards for pediatric neurosurgery were produced. Between 2001 and 2013 several key documents were published, which formed the background to the review that produced these standards:, the 'Safe and Sustainable' review. The process had the mission statement, 'Safe, sustainable and world class. Not ordinary, OK or just good enough.' In April 2013, the new commissioning structure of NHS England came into being. Clinical Reference Groups (reporting directly into the new structure) and pediatric neurosurgical operational delivery networks are taking the Safe and Sustainable pediatric neurosurgery standards and models of care into practice in England. Effective outcome data collection will allow us to assess whether these networks will improve equity of access for English children to world-class pediatric neurosurgical care and reduce the variation in outcomes seen at the present time.

Hospital volume of thoracoabdominal aneurysm repair does not affect mortality in California

OBJECTIVES

Open thoracoabdominal aneurysm repair (TAAR) is a rarely performed but a complicated and morbid procedure. This study compares the morbidity and mortality of open TAAR at high- versus low-volume hospitals.

METHODS

Included patients from California Office of Statewide Health Policy and Development patient discharge database who underwent an open TAAR between 1995 and 2010. High volume was ≥ 9 cases per year. Outcomes included mortality and postoperative complications. Multivariate analyses compared patients at high- versus low-volume hospitals.

RESULTS

A total of 122 hospitals were included, with 5 designated as high volume. Adjusted analysis found no difference in the odds ratio (OR) of mortality or morbidity at high-volume hospitals compared to low-volume hospitals (OR 0.37, P = .077; OR 0.94, P = .834, respectively). However, there was a decreased OR of mortality in high- versus low-volume hospitals when a high-volume hospital was defined as each year after meeting the initial threshold of 9 cases (OR 0.40, P = .040).

CONCLUSION

We found no difference in mortality between low- and high-volume institutions in California, until high-volume hospitals were defined as each year after meeting initial threshold case volume. This may suggest that the benefits of high-volume hospitals on outcomes are maintained after reaching the requisite case volume.

Creating an advance-care-planning decision aid for high-risk surgery: a qualitative study

BACKGROUND

High-risk surgery patients may lose decision-making capacity as a result of surgical complications. Advance care planning prior to surgery may be beneficial, but remains controversial and is hindered by a lack of appropriate decision aids. This study sought to examine stakeholders' views on the appropriateness of using decision aids, in general, to support advance care planning among high-risk surgery populations and the design of such a decision aid.

METHODS

Key informants were recruited through purposive and snowball sampling. Semi-structured interviews were conducted by phone until data collected reached theoretical saturation. Key informants were asked to discuss their thoughts about advance care planning and interventions to support advance care planning, particularly for this population. Researchers took de-identified notes that were analyzed for emerging concordant, discordant, and recurrent themes using interpretative phenomenological analysis.

RESULTS

Key informants described the importance of initiating advance care planning preoperatively, despite potential challenges present in surgical settings. In general, decision aids were viewed as an appropriate approach to support advance care planning for this population. A recipe emerged from the data that outlines tools, ingredients, and tips for success that are needed to design an advance care planning decision aid for high-risk surgical settings.

CONCLUSIONS

Stakeholders supported incorporating advance care planning in high-risk surgical settings and endorsed the appropriateness of using decision aids to do so. Findings will inform the next stages of developing the first advance care planning decision aid for high-risk surgery patients.

Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base

OBJECTIVE

To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days.

PATIENTS AND METHODS

The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35,055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals. Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10-19 procedures; high-volume hospital: ≥20 procedures). Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling.

RESULTS

Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively. Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3-1.9), and 1.2 (1.0-1.4), respectively.

CONCLUSIONS

A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata. The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.

Impact of centralization of pancreatic cancer surgery on resection rates and survival

BACKGROUND

Centralization of pancreatic surgery has been shown to reduce postoperative mortality. It is unknown whether resection rates and survival have also improved. The aim of this study was to analyse the impact of nationwide centralization of pancreatic surgery on resection rates and long-term survival.

METHODS

All patients diagnosed in the Netherlands between 2000 and 2009 with cancer of the pancreatic head were identified in the Netherlands Cancer Registry. Changes in referral pattern, resection rates and survival after pancreatoduodenectomy were analysed. Multivariable regression analysis was used to assess the impact of hospital volume (20 or more procedures per year) on survival after resection.

RESULTS

Between 2000 and 2009, 11,160 patients were diagnosed with cancer of the pancreatic head. The resection rate increased from 10.7 per cent in 2000-2004 to 15.3 per cent in 2005-2009 (P < 0.001). No significant difference in survival after resection was observed between the two intervals (P = 0.135), although survival was significantly better in high-volume hospitals (median survival 18 months versus 16 months in low/medium-volume hospitals; P = 0.017). After adjustment for patient and tumour characteristics, high hospital volume remained associated with better overall survival after resection (hazard ratio 0.70, 95 per cent confidence interval 0.58 to 0.84; P < 0.001).

CONCLUSION

Centralization of pancreatic cancer surgery led to increased resection rates. High-volume centres had significantly better survival rates. Centralization improves patient outcomes and should be encouraged.

Data-driven discovery of seasonally linked diseases from an Electronic Health Records system

BACKGROUND

Patterns of disease incidence can identify new risk factors for the disease or provide insight into the etiology. For example, allergies and infectious diseases have been shown to follow periodic temporal patterns due to seasonal changes in environmental or infectious agents. Previous work searching for seasonal or other temporal patterns in disease diagnosis rates has been limited both in the scope of the diseases examined and in the ability to distinguish unexpected seasonal patterns. Electronic Health Records (EHR) compile extensive longitudinal clinical information, constituting a unique source for discovery of trends in occurrence of disease. However, the data suffer from inherent biases that preclude an identification of temporal trends.

METHODS

Motivated by observation of the biases in this data source, we developed a method (Lomb-Scargle periodograms in detrended data, LSP-detrend) to find periodic patterns by adjusting the temporal information for broad trends in incidence, as well as seasonal changes in total hospitalizations. LSP-detrend can sensitively uncover periodic temporal patterns in the corrected data and identify the significance of the trend. We apply LSP-detrend to a compilation of records from 1.5 million patients encoded by ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), including 2,805 disorders with more than 500 occurrences across a 12 year period, recorded from 1.5 million patients.

RESULTS AND CONCLUSIONS

Although EHR data, and ICD-9 coded records in particular, were not created with the intention of aggregated use for research, these data can in fact be mined for periodic patterns in incidence of disease, if confounders are properly removed. Of all diagnoses, around 10% are identified as seasonal by LSP-detrend, including many known phenomena. We robustly reproduce previous findings, even for relatively rare diseases. For instance, Kawasaki disease, a rare childhood disease that has been associated with weather patterns, is detected as strongly linked with winter months. Among the novel results, we find a bi-annual increase in exacerbations of myasthenia gravis, a potentially life threatening complication of an autoimmune disease. We dissect the causes of this seasonal incidence and propose that factors predisposing patients to this event vary through the year.

Trends and variations in the rates of hospital complications, failure-to-rescue and 30-day mortality in surgical patients in New South Wales, Australia, 2002-2009

BACKGROUND

Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator.

METHODS

We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics.

RESULTS

The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group.

CONCLUSIONS

The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities.

Incidental diagnosis as prognostic factor in different tumor stages of nonfunctioning pancreatic endocrine tumors

BACKGROUND

Incidentally discovered nonfunctioning pancreatic endocrine tumors (NF-pNETs) increasingly are being detected, and their management is debated. Moreover, the prognostic importance of incidental diagnosis for locally advanced or metastatic NF-pNETs is unknown. The aim of this study is to analyze the outcomes of incidentally discovered/symptomatic NF-pNETs stratified by tumor stage. A preliminary experience with nonoperative treatment of incidental NF-pNETs is reported.

METHODS

Consecutive patients with symptomatic/incidental NF-PETs observed between 1990 and 2009 were analyzed, with different tumor stages considered. Nonoperative management of incidental NF-pNETs was evaluated.

RESULTS

Among 355 patients with NF-pNETs, the diagnosis was incidental in 124 (35%). Incidental NF-pNETs were associated more commonly with lower tumor stages compared with symptomatic tumors (P < .0001), but 30% of incidental NF-pNETs were stage III-IV. Incidental NF-pNETs had greater rates of radical resections and of R0 margins (P < .0001). Five-year progression-free survival (PFS) was 83% and 32% for incidental and symptomatic NF-pNETs, respectively (P < .0001). Five-year PFS was better for incidental NF-pNETs compared with symptomatic tumors for each tumor stage, including stage III (69% vs 27%, P < .0001) and stage IV (60% vs 17%, P = .112). After a median follow-up of 36 months, there was no tumor progression in 12 patients who underwent nonoperative management of incidental NF-pNETs.

CONCLUSION

A total of 30% of incidental NF-pNETs present with stage III-IV disease. PFS is much greater for incidental NF-pNETs compared with symptomatic patients, and this difference is evident also for stage III-IV tumors, suggesting that absence of symptoms may indicate a less-aggressive disease. Nonoperative management can be an alternative to surgery in selected incidental NF-pNETs.

Hospital case volume and outcomes among patients hospitalized with severe sepsis

RATIONALE

Processes of care are potential determinants of outcomes in patients with severe sepsis. Whether hospitals with more experience caring for patients with severe sepsis also have improved outcomes is unclear.

OBJECTIVES

To determine associations between hospital severe sepsis caseload and outcomes.

METHODS

We analyzed data from U.S. academic hospitals provided through University HealthSystem Consortium. We used University HealthSystem Consortium's sepsis mortality model (c-statistic, 0.826) for risk adjustment. Validated International Classification of Disease, 9th Edition, Clinical Modification algorithms were used to identify hospital severe sepsis case volume. Associations between risk-adjusted severe sepsis case volume and mortality, length of stay, and costs were analyzed using spline regression and analysis of covariance.

MEASUREMENTS AND MAIN RESULTS

We identified 56,997 patients with severe sepsis admitted to 124 U.S. academic hospitals during 2011. Hospitals admitted 460 ± 216 patients with severe sepsis, with median length of stay 12.5 days (interquartile range, 11.1-14.2), median direct costs $26,304 (interquartile range, $21,900-$32,090), and average hospital mortality 25.6 ± 5.3%. Higher severe sepsis case volume was associated with lower unadjusted severe sepsis mortality (R2 = 0.10, P = 0.01) and risk-adjusted severe sepsis mortality (R2 = 0.21, P < 0.001). After further adjustment for geographic region, number of beds, and long-term acute care referrals, hospitals in the highest severe sepsis case volume quartile had an absolute 7% (95% confidence interval, 2.4-11.6%) lower hospital mortality than hospitals in the lowest quartile. We did not identify associations between case volume and resource use.

CONCLUSIONS

Academic hospitals with higher severe sepsis case volume have lower severe sepsis hospital mortality without higher costs.

Beyond volume: does hospital complexity matter?: an analysis of inpatient surgical mortality in the United States

BACKGROUND

Hospitals show wide variation in outcomes and systems of care. It is unclear whether hospital complexity-the range of services and technologies provided-affects outcomes and in what direction. We sought to determine whether complexity was associated with inpatient surgical mortality.

METHODS

Using national Medicare data, we identified all fee-for-service inpatients who underwent 1 of 5 common high-risk surgical procedures in 2008-2009 and measured complexity by the number of unique primary diagnoses admitted to each hospital over the 2-year period. We calculated 30-day postoperative mortality rates, adjusting for patient and hospital characteristics, and used multivariable Poisson regression models to test for an association between hospital complexity and mortality rates. We then used this model to generate predicted mortality rates for low-volume and high-volume hospitals across the spectrum of hospital complexity.

RESULTS

A total of 2691 hospitals were analyzed, representing a total of 382,372 admissions. After adjusting for hospital characteristics, including hospital volume, increasing hospital complexity was associated with lower surgical mortality rates. Patients receiving care at the hospitals in the lowest quintile of unique diagnoses had a 27% higher risk of death than those at the highest quintile. The effect of complexity was largest for low-volume hospitals, which were capable of achieving mortality rates similar to high-volume hospitals when in the most complex quintile.

CONCLUSIONS

Hospital complexity matters and is associated with lower surgical mortality rates, independent of hospital volume. The effect of complexity on outcomes for nonsurgical services warrants investigation.

Coronary artery bypass grafting: Part 1--the evolution over the first 50 years

Surgical treatment for angina pectoris was first proposed in 1899. Decades of experimental surgery for coronary artery disease finally led to the introduction of coronary artery bypass grafting (CABG) in 1964. Now that we are approaching 50 years of CABG experience, it is appropriate to summarize the advancement of CABG into a procedure that is safe and efficient. This review provides a historical recapitulation of experimental surgery, the evolution of the surgical techniques and the utilization of CABG. Furthermore, data on contemporary clinical outcomes are discussed.

Patterns of surgical care and complications in elderly adults

OBJECTIVES

To determine whether procedures, hospitals visited, and complications would differ according to decade in elderly adults and from those of younger adults.

DESIGN

Retrospective cohort study.

SETTING

The Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (NACOR) is the largest database of anesthesia cases from academic and community hospitals and includes all insurance and facility types across the United States.

PARTICIPANTS

Eight million six hundred thirty-two thousand nine hundred seventy-nine cases from January 2010 to March 2013 were acquired. After exclusion of individuals younger than 18, nonapplicable locations, and brain death, 2,851,114 remained and were placed into age categories (18-64, 65-69, 70-79, 80-89, ≥ 90).

MEASUREMENTS

Participant, surgical, anesthetic, and hospital descriptors and short-term outcomes (major complications, mortality at <48 hours).

RESULTS

The largest number of older adults had surgery in medium-sized community hospitals. The oldest age group (≥ 90) underwent the smallest range of procedures; hip fracture, hip replacement, and cataract procedures accounted for more than 35% of all surgeries. Younger old adults underwent these procedures plus a significant proportion of spinal fusion, cholecystectomy, and knee surgery. Older adults had greater mortality and more complications than younger adults. Participants undergoing exploratory laparotomy had the greatest likelihood of death in any age category except 90 and older, in which small bowel resection predominated. The proportion of emergency surgery and the mortality associated with emergency surgery was 30% higher in the oldest group (≥ 90) than in adults aged 18 to 64.

CONCLUSION

This article reports the pattern of surgical procedures, complications, and mortality found in NACOR, which is one of the few data sets that contains data from community hospitals and individuals with all types of insurance. Because the outcomes portion of the data set is under development, it is not possible to investigate the relationship between hospital type and complications or mortality, but this study underscores the magnitude of geriatric surgery that occurs in community hospitals as an area for future outcomes studies.

Differences in perioperative care at low- and high-mortality hospitals with cancer surgery

OBJECTIVE

To evaluate adherence to perioperative processes of care associated with major cancer resections.

BACKGROUND

Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes.

METHODS

There were 1,279 hospitals participating in the National Cancer DataBase (2005-2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics.

RESULTS

Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50-0.92 and aRR 0.80, 95 % CI 0.56-0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90-1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81-1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32-0.93).

CONCLUSIONS

HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.

Racial variation in the quality of surgical care for bladder cancer

BACKGROUND

Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa.

METHODS

The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital.

RESULTS

Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile.

CONCLUSIONS

Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation.

Impact of surgeon and hospital volume on mortality, length of stay, and cost of pancreaticoduodenectomy

BACKGROUND

Improved mortality rates following pancreaticoduodenectomy by high-volume surgeons and hospitals have been well documented, but less is known about the impact of such volumes on length of stay and cost. This study uses data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) to examine the effect of surgeon and hospital volume on mortality, length of stay, and cost following pancreaticoduodenectomy while controlling for patient-specific factors.

METHODS

Data included 3,137 pancreaticoduodenectomies from the NIS performed between 2004 and 2008. Using logistic regression, the relationship between surgeon volume, hospital volume, and postoperative mortality, length of stay, and cost was estimated while accounting for patient factors.

RESULTS

After controlling for patient characteristics, patients of high-volume surgeons at high-volume hospitals had a significantly lower risk of mortality compared to low-volume surgeons at low-volume hospitals (OR 0.32, p < 0.001). Patients of high-volume surgeons at high-volume hospitals also had a five day shorter length of stay (p < 0.001), as well as significantly lower costs (US$12,275, p < 0.001).

CONCLUSIONS

The results of this study, which simultaneously accounted for surgeon volume, hospital volume, and potential confounding patient characteristics, suggest that both surgeon and hospital volume have a significant effect on outcomes following pancreaticoduodenectomy, affecting not only mortality rates but also lengths of stay and costs.

National trends in pancreatic cancer outcomes and pattern of care among Medicare beneficiaries, 2000 through 2010

BACKGROUND

Pancreatic cancer is a major cause of morbidity and mortality in the Medicare population. Whether the health care burden of pancreatic cancer has changed over the last decade is unknown.

METHODS

The authors used Medicare data from 2000 to 2010 to identify beneficiaries aged ≥ 65 years who were hospitalized for the management of pancreatic cancer. Annual trends were estimated for the age-sex-race-adjusted initial hospitalization rate, the age-sex-race-comorbidity-adjusted 1-year mortality rate after initial hospitalization, age-sex-race-comorbidity-adjusted procedure rates, 1-year all-cause rehospitalizations after initial pancreatic cancer hospitalization, and mean inflation-adjusted Medicare payment for initial hospitalization.

RESULTS

A total of 130,728 patients had ≥ 1 hospitalizations for pancreatic cancer and were identified from 56,642,071 beneficiaries during the study period. The age-sex-race-adjusted rate of initial hospitalization for pancreatic cancer was 50 per 100,000 person-years in 2010, representing a 0.5% annual increase since 2000 (95% confidence interval [95% CI], 0.3%-0.7%). In the same period, the age-sex-race-comorbidity-adjusted 1-year mortality rate decreased by 4.4% (95% CI, 3.9%-4.9%), and the age-sex-race-comorbidity-adjusted surgical resection rate increased by 6.9% (95% CI, 6.4%-7.5%). The mean inflation-adjusted Medicare payment for the initial hospitalization decreased, from $14,118 in 2000 to $13,318 in 2010, and the number of 1-year all-cause rehospitalizations after the initial hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (all P < .001).

CONCLUSIONS

For Medicare fee-for-service beneficiaries, initial pancreatic cancer hospitalization, surgical resection, and rehospitalization rates increased, but 1-year mortality rates declined over the last decade.

The influence of complications on the costs of complex cancer surgery

BACKGROUND

It is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care.

METHODS

The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs.

RESULTS

Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs-including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism-raised hospitalization costs by ≥20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections.

CONCLUSIONS

The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement.

Pancreaticoduodenectomy--the transition from a low- to a high-volume center

OBJECTIVE

Previous studies have identified a significant volume-outcome relationship for hospitals performing pancreaticoduodenectomy (PD). However, scant information exists concerning the effects of increased caseload of PD within the same hospital. Here, we describe the effects of becoming a high-volume provider of PD.

MATERIAL AND METHODS

The study group comprised 221 patients who underwent PD between 2000 and 2012. Hospital volume was allocated into three groups: low-volume (<10 PDs/year), years 2000-2004, n = 25; medium-volume (10-24 PDs/year), years 2005-2009, n = 86; and high-volume (≥25 PDs/year), years 2010-2012, n = 110.

RESULTS

The annual number of PDs increased from 5 in 2000 to 39 in 2012. The median operative duration decreased over the volume categories (p < 0.001). Intraoperative blood loss dropped (p < 0.001). The need for intraoperative blood transfusion was reduced (p < 0.001). Increasing hospital volume was associated with fewer reoperations (p = 0.041) and shorter postoperative length of stay (p = 0.010). There was a tendency toward reduced mortality: 4.0% for the low-volume period, 2.3% for the medium-volume period, and 0% for the high-volume period (p = 0.066).

CONCLUSIONS

The transition from a low- to a high-volume center resulted in optimized outcomes for PD and 0% operative mortality, favoring the continued centralization of this high-risk operation.

Whipple made simple for surgical pathologists: orientation, dissection, and sampling of pancreaticoduodenectomy specimens for a more practical and accurate evaluation of pancreatic, distal common bile duct, and ampullary tumors

Pancreaticoduodenectomy (PD) specimens present a challenge for surgical pathologists because of the relative rarity of these specimens, combined with the anatomic complexity. Here, we describe our experience on the orientation, dissection, and sampling of PD specimens for a more practical and accurate evaluation of pancreatic, distal common bile duct (CBD), and ampullary tumors. For orientation of PDs, identification of the "trapezoid," created by the vascular bed at the center, the pancreatic neck margin on the left, and the uncinate margin on the right, is of outmost importance in finding all the pertinent margins of the specimen including the CBD, which is located at the upper right edge of this trapezoid. After orientation, all the margins can be sampled. We submit the uncinate margin entirely as a perpendicular inked margin because this adipose tissue-rich area often reveals subtle satellite carcinomas that are grossly invisible, and, with this approach, the number of R1 resections has doubled in our experience. Then, to ensure proper identification of all lymph nodes (LNs), we utilize the orange-peeling approach, in which the soft tissue surrounding the pancreatic head is shaved off in 7 arbitrarily defined regions, which also serve as shaved samples of the so-called "peripancreatic soft tissue" that defines pT3 in the current American Joint Committee on Cancer TNM. With this approach, our LN count increased from 6 to 14 and LN positivity rate from 50% to 73%. In addition, in 90% of pancreatic ductal adenocarcinomas there are grossly undetected microfoci of carcinoma. For determination of the primary site and the extent of the tumor, we believe bisectioning of the pancreatic head, instead of axial (transverse) slicing, is the most revealing approach. In addition, documentation of the findings in the duodenal surface of the ampulla is crucial for ampullary carcinomas and their recent site-specific categorization into 4 categories. Therefore, we probe both the CBD and the pancreatic duct from distal to the ampulla and cut the pancreatic head to the ampulla at a plane that goes through both ducts. Then, we sample the bisected pancreatic head depending on the findings of the case. For example, for proper staging of ampullary carcinomas, it is imperative to take the sections perpendicular to the duodenal serosa at the "groove" area, as ampullary carcinomas often extend to this region. Amputative (axial) sectioning of the ampulla, although good for documentation of the peri-Oddi spread of the intra-ampullary tumors, unfortunately disallows documentation of mucosal spread of the papilla of Vater tumors (those arising from the edge of the ampulla, where the ducts transition to duodenal mucosa and extending) into the neighboring duodenum. Axial sectioning also often fails to document tumor spread to the "groove" area. In conclusion, knowledge of the gross characteristics of the anatomic hallmarks is essential for proper dissection of PD specimens. The approach described above allows practical and accurate documentation and staging of pancreas, distal CBD, and ampullary cancers.

It's big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations

OBJECTIVE

To identify the processes, surgeons use to establish patient buy-in to postoperative treatments.

BACKGROUND

Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown.

METHODS

We used purposive sampling to identify 3 surgeons from different subspecialties who routinely perform high-risk operations at each of 3 distinct medical centers (Toronto, Ontario; Boston, Massachusetts; Madison, Wisconsin). We recorded preoperative conversations with 3 to 7 patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively.

RESULTS

Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is "big surgery" and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients' questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly.

CONCLUSIONS

Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients' desires for prolonged postoperative life support on the basis of these preoperative conversations alone.

Risk factors associated with mortality after Roux-en-Y gastric bypass surgery

OBJECTIVE

We sought to identify the major risk factors associated with mortality in Roux-en-Y gastric bypass (RYGB) surgery.

BACKGROUND

Bariatric surgery has become an established treatment for extreme obesity. Bariatric surgery mortality has steadily declined with current rates of less than 0.5%. However, significant variation in the mortality rates has been reported for specific patient cohorts and among bariatric centers.

METHODS

Clinical outcome data from 185,315 bariatric surgery patients from the Bariatric Outcome Longitudinal Database were reviewed. Of these, 157,559 patients had either documented 30 or more day follow-up data, including mortality. Multiple demographic, socioeconomic, and clinical factors were analyzed by univariate analysis for their association with 30-day mortality after gastric bypass. Variables found to be significant were entered into a multiple logistic regression model to identify factors independently associated with 30-day mortality. On the basis of these results, a RYGB mortality risk score was developed.

RESULTS

The overall 30-day mortality rate for the entire bariatric surgery cohort was 0.1%. Of the 81,751 RYGB patients, the mortality rate was 0.15%. Factors significantly associated with 30-day gastric bypass mortality included increasing body mass index (BMI) (P<0.0001), increasing age (P<0.005), male gender (P<0.001), pulmonary hypertension (P<0.0001), congestive heart failure (P=0.0008), and liver disease (P=0.038). When the RYGB risk score was applied, a significant trend (P<0.0001) between increasing risk score and mortality rate is found.

CONCLUSIONS

Increasing BMI, increasing age, male gender, pulmonary hypertension, congestive heart failure, and liver disease are risk factors for 30-day mortality after RYGB. The RYGB risk score can be used to determine patients at greater risk for mortality after RYGB surgery.

Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial

OBJECTIVE

To investigate the relationship between the route of gastroenteric (GE) reconstruction after pancreatoduodenectomy (PD) and the postoperative incidence of delayed gastric emptying (DGE).

BACKGROUND

DGE is one of the most common complications after PD. Recent studies suggest that an antecolic route of the GE reconstruction leads to a lower incidence of DGE, compared to a retrocolic route. In a nonrandomized comparison within our trial center, we found no difference in DGE after antecolic or retrocolic GE reconstruction.

METHODS

Ten middle- to high-volume centers participated in the patient inclusion. Patients scheduled for PD who gave written informed consent were included and randomized during surgery after resection. Standard operation was a pylorus-preserving PD. Primary endpoint was DGE. Secondary endpoints included other complications and length of hospital stay.

RESULTS

There were 125 patients in the retrocolic group, and 121 patients in the antecolic group. Baseline and treatment characteristics did not differ between the study groups. In the retrocolic group, 45 patients (36%) developed clinically relevant DGE compared with 41 (34%) in the antecolic group (absolute risk difference: 2.1%; 95% confidence interval: -9.8% to 14.0%). There were no differences in need for postoperative (par)enteral nutritional support, other complications, hospital mortality, and median length of hospital stay.

CONCLUSIONS

The route of GE reconstruction after PD does not influence the postoperative incidence of DGE or other complications. The etiology and treatment of DGE, which occurs frequently after both procedures, need further investigation. The GE reconstruction after PD should be routed according to the surgeon's preference.

Lung protective ventilation in patients undergoing major surgery: a systematic review protocol

INTRODUCTION

There is growing interest in the use of low tidal volume ventilation in patients undergoing general anaesthesia. However, its potential benefit has long been debated and conflicting results have been reported. We describe here the protocol of a systematic review and meta-analysis for investigating the beneficial effects of low tidal volume ventilation in patients undergoing general anaesthesia.

METHODS AND ANALYSIS

Data sources include PubMed, Scopus, Embase and EBSCO. Patients undergoing general anaesthesia will be included irrespective of type of surgery. The intervention is low tidal volume ventilation or protective ventilation, and the control is conventional ventilation. The quality of included trials will be assessed by using Delphi consensus. Outcomes include new onset lung injury, atelectasis, arrhythmia, levels of inflammatory biomarkers, arterial oxygenation, partial pressure of carbon dioxide and alveolar-arterial oxygen gradient. Conventional approaches for meta-analysis will be used, and heterogeneity will be investigated by using subgroup analysis and meta-regression if appropriate. The Bayesian method will be used for the synthesis of binary outcome data.

ETHICS AND DISSEMINATION

The systematic review was approved by the ethics committee of Jinhua hospital of Zhejiang university and will be published in a peer-reviewed journal and will be disseminated electronically and in print.

REGISTRATION DETAILS

The study protocol has been registered in PROSPERO (http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42013006416.

Evaluation of Medicare claims data to ascertain peripheral vascular events in the Women's Health Initiative

OBJECTIVE

Capturing long-term outcomes from large clinical databases by use of claims data is a potential strategy for improving efficiency while reducing study costs. We sought to compare the use of Medicare data with data from the Women's Health Initiative (WHI) to determine peripheral vascular events, as defined by the WHI study design.

METHODS

We studied participants from the WHI with both adjudicated outcomes and links to Medicare enrollment and utilization data through 2007. Outcomes of interest included hospitalizations for treatment of abdominal aortic aneurysm (AAA), lower extremity peripheral artery disease (LE PAD), and carotid artery stenosis (CAS). Events determined by WHI adjudication were compared with events defined by coding algorithms using diagnosis and procedure codes from Medicare data with a pilot data set and then validated with a test data set. We assessed agreement by a κ statistic and evaluated reasons for disagreement.

RESULTS

In the pilot set, records from 50,511 participants were analyzed. Agreement between the Centers for Medicare and Medicaid Services and WHI for admissions with a diagnosis but no treatment procedures for vascular conditions was poor (κ, 0.02-0.18). On the basis of WHI outcome data collection, vascular treatment procedures occurred in 29 participants for AAA, 204 for LE PAD events, and 281 for CAS. Medicare hospital claims recorded 41 treatments for AAA, 255 for LE PAD, and 317 for CAS. For participants with a Centers for Medicare and Medicaid Services-captured vascular procedure and a record adjudicated by WHI, κ values for treatment procedures were 0.81 for AAA, 0.77 for PAD, and 0.93 for CAS. For vascular procedures identified by WHI but not by Medicare hospital data (n = 82), 55% were captured by Medicare physician claims. Conversely, for treatments identified by Medicare hospital data but not captured by WHI adjudication (n = 57), 74% had physician claims consistent with the procedure. Fifteen participants with AAA or LE PAD procedures in hospital claims had medical records available for review, and nine of these had definitive documentation of procedures that were not captured by the WHI adjudication process. Estimated positive predictive value of Medicare data was 91% to 94% for AAA, 92% to 95% for LE PAD, and 94% to 99% for CAS. Available test set data (n = 50,253) yielded generally similar results with κ of 0.77 for AAA, 0.79 for LE PAD, and 0.94 for CAS.

CONCLUSIONS

Medicare data appear useful for identifying vascular treatment procedures for WHI participants. Medicare hospital claims identify more procedures than WHI does, with high positive predictive value, but also may not capture some procedures identified in WHI.

Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA

BACKGROUND

Recent publications demonstrate regionalization of complex operations to high-volume centers (HVCs) in the USA. We hypothesize that this pattern applies to hepato-pancreato-biliary (HPB) cancer resections and improved outcomes.

METHODS

The Nationwide Inpatient Sample (NIS) data were analyzed from 1995-1999(T1) to 2005-2009(T2) for all HPB oncologic resections. Division of hospitals into high-, mid-, and low-volume centers (HVC, MVC, LVC) was performed. Multivariate regression was utilized to identify predictors of LVC resection. Outcomes were compared in both eras.

RESULTS

A total of 45,815 cases met the inclusion criteria (19,250 from T1 and 25,565 from T2). At T1, 32.5% of resections were performed at HVCs and 34.9% at LVCs. At T2, 60.8% were performed at HVCs versus 18.5% at LVCs. In T1, inpatient mortality at HVCs versus LVCs was 3.3% versus 8.67% (p < 0.0001) and 2.7% versus 6.5% (p < 0.0001) in T2. LOS and routine discharge were improved in HVCs, but total charges were higher. All outcomes significantly differed between HVCs and LVCs in multivariate analysis, except for LOS and total charges in T2.

CONCLUSION

The most recent NIS data demonstrate better outcomes in HVCs for HPB oncologic resections. These trends reflect alignment with national recommendations to centralize complex cancer surgery, as well as improved outcomes in all centers.

Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy

BACKGROUND

High morbidity and mortality rates after pancreaticoduodenectomy (PD) have led to concentration of this surgery in high-volume centres, with improved outcomes. The extent to which better outcomes might be apparent in a healthcare system where the mortality rate is already low is unclear.

METHODS

The Japanese Diagnosis Procedure Combination database was used to identify patients undergoing PD between 2007 and 2010. Patient data included age, sex, co-morbidities at admission, type of hospital, type of PD, and the year in which the patient was treated. Hospital volume was defined as the number of PDs performed annually at each hospital, and categorized into quintiles: very low-, low-, medium-, high- and very high-volume groups. The Charlson co-morbidity index was calculated using the International Classification of Diseases, tenth revision, codes of co-morbidities.

RESULTS

A total of 10 652 patients who underwent PD in 848 hospitals were identified. The overall in-hospital mortality rate after PD was 3·3 per cent (350 of 10 652), and for the groups ranged from 5·0 per cent for the very low-volume group to 1·4 per cent for the very high-volume group (P < 0·001). Multivariable analysis revealed a significant linear relationship between higher hospital volume and shorter postoperative length of stay compared with the very low-volume group, and between increasing hospital volume and lower total costs.

CONCLUSION

A significant relationship exists between increasing hospital volume, lower in-hospital mortality, shorter length of stay and lower costs for patients undergoing PD in Japan. Centralization of PD in this healthcare system is therefore justified.

Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study

BACKGROUND

The escalation of care process has not been explored in surgery, despite the role of communication failures in adverse events. This study aimed to develop a conceptual framework of the influences on escalation of care in surgery allowing solutions to facilitate management of sick patients to be developed.

METHODS

A multicenter qualitative study was conducted in three hospitals in London, UK. A total of 41 participants were recruited, including 16 surgeons, 11 surgical PGY1s, six surgical nurses, four intensivists, and four critical care outreach team members. Participants were submitted to semistructured interviews that were analyzed using grounded theory methodology.

RESULTS

A decision to escalate was based upon five key themes: patient, individual, team, environmental, and organizational factors. Most participants felt that supervision and escalation of care were problematic in their hospital, with unclear escalation protocols and poor availability of senior surgical staff the most common concerns. Mobile phones and direct conversation were identified to be more effective when escalating care than hospital pager systems. Transparent escalation protocols, increased senior clinician supervision, and communication skills training were highlighted as strategies to improve escalation of care.

CONCLUSION

This is the first study to describe escalation of care in surgery, a key process for protecting the safety of deteriorating surgical patients. Factors affecting the decision to escalate are complex, involving clinical and professional aspects of care. An understanding of this process could pave the way for interventions to facilitate escalation in order to improve patient outcome.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

A comparative international study on the management of acute appendicitis between a developed country and a middle income country

BACKGROUND

In the past decade there has been an exponential increase in the use of Computerised Tomography (CT) imaging in the assessment of patients with acute appendicitis. The aim of this study was to compare management approaches and clinical outcomes of acute appendicitis in Sri Lanka and the United Kingdom.

METHODS

Data was collected prospectively from 400 patients referred to the General Surgical department with a differential diagnosis of acute appendicitis, 200 at University Kelaniya Sri Lanka (SL group), and 200 at University College London Hospital (UK group).

RESULTS

The groups were similar with respect to gender, but the SL group was younger. Preoperative work-up included ultrasound more commonly in SL patients, and CT more commonly in UK patients. More patients underwent appendicectomy in the SL group, however a laparoscopic approach was utilised more often in the UK group (50.5% vs. 11.9%). Post-operative complications were similarly represented in both groups, but re-admission occurred with greater frequency in the UK group (16.2% vs. 0%). Histologically confirmed appendicitis was seen in a significantly greater proportion of SL patients (93.1% vs. 79.8%). Multivariate analysis confirmed male gender, and diagnosis and treatment in Sri Lanka to be only factors significantly associated with positive appendicitis.

DISCUSSION

Expensive investigations such as CT do not appear to improve the diagnostic accuracy of appendicitis or prevent complications. This study suggests diagnostic and treatment algorithms in the SL hospital are more accurate and efficient in confirming appendicitis than those seen in the UK hospital under investigation.

Office-based injection laryngoplasty for the management of unilateral vocal fold paralysis

OBJECTIVE

Office-based injection laryngoplasty (OBIL) is a common method of addressing glottal insufficiency. This retrospective chart review identifies the demongraphics, laterality, technique, success rate, injectates, and complications of OBIL performed over a 3-year period at a single institution.

STUDY DESIGN

Retrospective chart review.

METHODS

All OBILs performed for the management of UVFP by the senior author over 3 years (2007-2009) were identified from billing records. The age, gender, laterality, underlying disease process, augmentation material, route of injection, and complications were recorded.

RESULTS

Eighty-two OBILs were attempted on 57 patients. The most common route of access was transoral (85.6%). All OBILs were able to be completed. Injectates used were hyaluronic acid derivatives (57.3%), calcium hydroxyapatite (16%), and Cymmetra (16.5%). Three complications (3.7%) occurred. Thirty percent of patients ultimately elected for thyroplasty or ansa reinnervation, 22% found their condition to self-resolve, 14% died, and 25% were lost to follow-up.

CONCLUSIONS

Using a variety of approaches, OBIL is possible in almost all patients. The single surgeon transoral route using a rigid angled telescope and curved injection needle was the most commonly used approach. Multiple injectates can be used and have good safety records. The final disposition of patients may be variable and warrants further investigation.

Extended neoadjuvant chemotherapy for borderline resectable pancreatic cancer demonstrates promising postoperative outcomes and survival

BACKGROUND

The optimum approach to neoadjuvant therapy for patients with borderline resectable pancreatic cancer is undefined. Herein we report the outcomes of an extended neoadjuvant chemotherapy regimen in patients presenting with borderline resectable adenocarcinoma of the pancreatic head.

METHODS

Patients identified as having borderline resectable pancreatic head cancer by American Hepato-Pancreato-Biliary Association/Society of Surgical Oncology consensus criteria from 2008 to 2012 were tracked in a prospectively maintained registry. Included patients were initiated on a 24-week course of neoadjuvant chemotherapy. Medically fit patients who completed neoadjuvant treatment without radiographic progression were offered resection with curative intent. Clinicopathologic variables and surgical outcomes were collected retrospectively and analyzed.

RESULTS

Sixty-four patients with borderline resectable pancreatic cancer started neoadjuvant therapy. Thirty-nine (61 %) met resection criteria and underwent operative exploration with curative intent, and 31 (48 %) were resected. Of the resected patients, 18 (58 %) had positive lymph nodes, 15 (48 %) required en-bloc venous resection, 27 (87 %) had a R0 resection, and 3 (10 %) had a complete pathologic response. There were no postoperative deaths at 90 days, 16 % of patients had a severe complication, and the 30-day readmission rate was 10 %. The median overall survival of all 64 patients was 23.6 months, whereas that of unresectable patients was 15.4 months. Twenty-five of the resected patients (81 %) are still alive at a median follow-up of 21.6 months.

CONCLUSIONS

Extended neoadjuvant chemotherapy is well tolerated by patients with borderline resectable pancreatic head adenocarcinoma, selects a subset of patients for curative surgery with low perioperative morbidity, and is associated with favorable survival.

[Morbidity, mortality, and overall survival after radical cystectomy: comparison of single-center results with the literature and a nomogram]

BACKGROUND

Overall survival (OS) after radical cystectomy is determined. It is investigated retrospectively whether prediction is possible using a nomogram. A comparison with published data from "high-volume" centers is performed.

PATIENTS AND METHODS

Data of 100 consecutive radical cystectomies performed between 2006 and 2012 were collected. Age, ASA score, tumor stage, urinary diversion, and Clavien score were recorded. The OS after 2 and 5 years was recorded (Kaplan-Meier analysis) and the nomogram-based predictive accuracy was calculated.

RESULTS

Median age was 70.8 years. A T≤2, T3, T4, N+ stage was present in 40, 37, 23, and 43%, respectively. Urinary diversion: neobladder, conduit, and ureterostomy were performed in 35, 53, and 12%. The 30-day mortality was 1%. At follow-up, there were 95 patients with a median observation time of 19.8 months. The 2- and 5-year OS were 0.68 and 0.45 (Kaplan-Meier analysis) and 0.65 and 0.39, respectively (nomogram). A significant correlation was observed (rs=0.79; rs=0.80). Compared to published "high-volume" series, no relevant differences concerning morbidity, mortality, and OS were observed. However, there are significant differences concerning the characteristics of "high-volume centers".

CONCLUSION

In this series, the OS can be predicted by a multivariate nomogram. The results are comparable with published data. There is no clear definition of a "high-volume center".

Lower provider volume is associated with higher failure rates for endoscopic retrograde cholangiopancreatography

BACKGROUND

Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown.

OBJECTIVE

Quantify the ERCP volume-outcome relationship by measuring provider-specific failure rates, hospitalization rates, and other quality measures.

RESEARCH DESIGN

Retrospective cohort.

SUBJECTS

A total of 16,968 ERCPs performed by 130 physicians between 2001 and 2011, identified in the Indiana Network for Patient Care.

MEASURES

Physicians were classified by their average annual Indiana Network for Patient Care volume and stratified into low (<25/y) and high (≥25/y). Outcomes included failed procedures, defined as repeat ERCP, percutaneous transhepatic cholangiography or surgical exploration of the bile duct≤7 days after the index procedure, hospitalization rates, and 30-day mortality.

RESULTS

Among 15,514 index ERCPs, there were 1163 (7.5%) failures; the failure rate was higher among low (9.5%) compared with high volume (5.7%) providers (P<0.001). A second ERCP within 7 days (a subgroup of failure rate) occurred more frequently when the original ERCP was performed by a low-volume (4.1%) versus a high-volume physician (2.3%, P=0.013). Patients were more frequently hospitalized within 24 hours when the ERCP was performed by a low-volume (28.3%) versus high-volume physician (14.8%, P=0.002). Mortality within 30 days was similar (low=1.9%, high=1.9%). Among low-volume physicians and after adjusting, the odds of having a failed procedure decreased 3.3% (95% confidence interval, 1.6%-5.0%, P<0.001) with each additional ERCP performed per year.

CONCLUSIONS

Lower provider volume is associated with higher failure rate for ERCP, and greater need for postprocedure hospitalization.

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery

Background

Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery.

Methods

All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality.

Results

A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (r_s = 0·957, P < 0·001 versus 180-day mortality; r_s = 0·860, P < 0·001 versus 365-day mortality).

Conclusion

Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.