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Clark JM, Boffa DJ, Meguid RA, Brown LM, Cooke DT. Regionalization of esophagectomy: where are we now? J Thorac Dis 2019; 11:S1633-S1642. [PMID: 31489231 DOI: 10.21037/jtd.2019.07.88] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert A Meguid
- Division of Thoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
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153
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Outcomes After Resection of Hepatocellular Carcinoma: Intersection of Travel Distance and Hospital Volume. J Gastrointest Surg 2019; 23:1425-1434. [PMID: 31069637 DOI: 10.1007/s11605-019-04233-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data on the impact of hospital volume and travel distance on patient outcomes after major abdominal surgery remain poorly defined. We sought to characterize the relationship of travel distance, hospital volume, and long-term outcomes of patients undergoing surgical resection of hepatocellular carcinoma (HCC). METHODS The 2004-2015 National Cancer Database was used to identify patients who underwent resection of HCC. Patients were stratified according to travel distance and hospital volume quartiles, and multivariable regression models were utilized to examine the impact of travel distance, hospital volume, and travel distance/hospital volume on overall survival (OS). RESULTS Among the 12,266 patients identified, procedures included wedge/segmental resections (N = 7354, 59.9%), hemi-hepatectomy (N = 4003, 32.6%), and extended hepatectomy (N = 909, 7.5%). Stratifying data into quartiles, travel distance to surgical care was ≤ 5.7 miles (mi), > 5.7-14.2 mi, > 14.2-44.4 mi, and ≥ 44.4 mi, while hospital volume quartiles determined on the hospital level were ≤ 1 case per year, 1.1-4, 4.1-12.5, and ≥ 12.5. On multivariable analysis, increased hospital volume was associated with decreased hazard of mortality (HR 0.69, 95% CI 0.45-0.82, p < 0.001). Travel distance was not significantly associated with hazard of mortality. Furthermore, only hospital volume was associated with mortality (HR 0.67, 95% CI 0.56-0.80, p < 0.001) after controlling for both travel distance and hospital volume. CONCLUSIONS Only hospital volume was associated with increased hazard of mortality. The benefits of undergoing resection for HCC at a high-volume hospital appear to outweigh the inconvenience of longer travel distances.
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Tanaka M, Heckler M, Mihaljevic AL, Probst P, Klaiber U, Heger U, Hackert T. Meta-analysis of effect of routine enteral nutrition on postoperative outcomes after pancreatoduodenectomy. Br J Surg 2019; 106:1138-1146. [PMID: 31241185 DOI: 10.1002/bjs.11217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal nutritional treatment after pancreatoduodenectomy is still unclear. The aim of this meta-analysis was to investigate the impact of routine enteral nutrition following pancreatoduodenectomy on postoperative outcomes. METHODS RCTs comparing enteral nutrition (regular oral intake with routine tube feeding) with non-enteral nutrition (regular oral intake with or without parenteral nutrition) after pancreatoduodenectomy were sought systematically in the MEDLINE, Cochrane Library and Web of Science databases. Postoperative data were extracted. Random-effects meta-analyses were performed to compare postoperative outcomes in the two arms, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 per cent confidence intervals. In subgroup analyses, the routes of nutrition were assessed. Percutaneous tube feeding and nasojejunal tube feeding were each compared with parenteral nutrition. RESULTS Eight RCTs with a total of 955 patients were included. Enteral nutrition was associated with a lower incidence of infectious complications (OR 0·66, 95 per cent c.i. 0·43 to 0·99; P = 0·046) and a shorter length of hospital stay (MD -2·89 (95 per cent c.i. -4·99 to -0·80) days; P < 0·001) than non-enteral nutrition. Percutaneous tube feeding had a lower incidence of infectious complications (OR 0·47, 0·25 to 0·87; P = 0·017) and a shorter hospital stay (MD -1·56 (-2·13 to -0·98) days; P < 0·001) than parenteral nutrition (3 RCTs), whereas nasojejunal tube feeding was not associated with better postoperative outcomes (2 RCTs). CONCLUSION As a supplement to regular oral diet, routine enteral nutrition, especially via a percutaneous enteral tube, may improve postoperative outcomes after pancreatoduodenectomy.
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Affiliation(s)
- M Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - A L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - U Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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155
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Stevens CL, Watters DAK. Short-term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume. ANZ J Surg 2019; 89:1577-1581. [PMID: 31222880 DOI: 10.1111/ans.15298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a high-risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short-term outcomes of the procedure in the Australian state of Victoria. METHODS The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30-day readmission rates and median length of stay were reported for each de-identified hospital. RESULTS There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume. CONCLUSION The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short-term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long-term PD outcomes.
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Affiliation(s)
- Claire L Stevens
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - David A K Watters
- Department of Surgery, University Hospital Geelong, Geelong, Melbourne, Australia
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156
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Merath K, Chen Q, Johnson M, Mehta R, Beal EW, Dillhoff M, Cloyd J, Pawlik TM. Hot spotting surgical patients undergoing hepatopancreatic procedures. HPB (Oxford) 2019; 21:765-772. [PMID: 30497897 DOI: 10.1016/j.hpb.2018.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The burden of health care spending in the United States is a major concern, as health care costs have exponentially increased during the last three decades. The objective of the current study was to investigate the degree of cost-concentration among Medicare patients undergoing liver and pancreatic surgery. METHODS Medicare claims data from 2013 to 2015 were used to identify patients undergoing elective liver and pancreatic resections. Patients were divided into four groups: 1) non-complex pancreatic procedures; 2) complex pancreatic procedures; 3) non-complex liver procedures; and 4) complex liver procedures. Unadjusted price-standardized Medicare payments were calculated and payments were divided into quintiles. Patient-level factors associated with payments were analyzed by multivariable linear regression. RESULTS A total of 17,125 patients were included in the study. Patients in the top quintile of spending accounted for over 40% of payments for all liver and pancreatic procedures. Patients with comorbidity scores ≥5, male sex, open surgical approach and a diagnosis of congestive heart failure were associated with higher costs. CONCLUSION Patients undergoing liver and pancreatic resections on the top 20% of payments were responsible for a disproportionate share of Medicare payments - over 40% of total expenditures. Overall hospital surgical volume was lower among the highest quintile of payments.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Morgan Johnson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Sonnenberg EM, Cohen JB, Hsu JY, Potluri VS, Levine MH, Abt PL, Reese PP. Association of Kidney Transplant Center Volume With 3-Year Clinical Outcomes. Am J Kidney Dis 2019; 74:441-451. [PMID: 31076173 DOI: 10.1053/j.ajkd.2019.02.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/26/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume-outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ≥65 years), and recipients of high kidney donor profile index (KDPI ≥ 85) kidneys. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult kidney-only transplant recipients who underwent transplantation between 2009 and 2013 (N = 79,581). EXPOSURES The primary exposure variable was center volume, categorized into quartiles based on the total kidney transplantation volume. Quartile 1 (Q1) centers performed a mean of fewer than 66 kidney transplantations per year, whereas Q4 centers performed a mean of more than 196 kidney transplantations per year. OUTCOMES All-cause graft failure and mortality within 3 years of transplantation. ANALYTICAL APPROACH Multivariable Cox frailty models were used to adjust for donor characteristics, recipient characteristics, and cold ischemia time. RESULTS Minor differences in rates of 3-year deceased donor all-cause graft failure across quartiles of center volume were observed (14.9% for Q1 vs 16.7% for Q4), including in subgroups (diabetic recipients, 18.4% for Q1 vs 19.7% for Q4; older recipients, 19.4% for Q1 vs 22.5% for Q4; recipients of high KDPI kidneys, 26.5% for Q1 vs 26.5% for Q4). Results were similar for 3-year mortality. After adjustment for donor, recipient, and graft characteristics using Cox regression, center volume was not significantly associated with all-cause graft failure or mortality within 3 years, except that diabetic recipients at Q3 centers had slightly lower mortality (compared with Q1 centers, adjusted HR of 0.85 [95% CI, 0.73-0.99]). LIMITATIONS Potential unmeasured confounding from patient comorbid conditions and organ selection. CONCLUSIONS These findings provide little evidence that care in higher volume centers is associated with better adjusted outcomes for kidney transplant recipients, even in populations anticipated to be at increased risk for graft failure or death.
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Affiliation(s)
- Elizabeth M Sonnenberg
- Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Jesse Y Hsu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Vishnu S Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.
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Soufi M, Yip-Schneider MT, Carr RA, Roch AM, Wu HH, Schmidt CM. Multifocal High-Grade Pancreatic Precursor Lesions: A Case Series and Management Recommendations. J Pancreat Cancer 2019; 5:8-11. [PMID: 31289790 PMCID: PMC6608687 DOI: 10.1089/pancan.2019.0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: The risk of developing invasive cancer in the remnant pancreas after resection of multifocal high-grade pancreatic precursor lesions is not well known. We report three patients who were followed up after resection of multifocal high-grade pancreatic intraepithelial neoplasia (PanIN)-3 or intraductal papillary mucinous neoplasia (IPMN), two of whom eventually developed invasive carcinoma. Presentation: 1) 68-year-old woman who had a laparoscopic distal pancreatectomy for multifocal mixed-type IPMN, identified as high-grade on final pathology, with negative surgical margins. During semiannual monitoring, eight years from the first surgery, the patient developed suspicious features prompting surgical resection of the body with final pathology revealing invasive ductal adenocarcinoma in the setting of IPMN. 2) 48-year-old woman who had a distal pancreatectomy for severe acute/chronic symptomatic pancreatitis, with final pathology revealing multifocal high-grade PanIN-3, with negative surgical margins. Despite semiannual monitoring, two years from the first surgery, the patient developed pancreatic adenocarcinoma with liver metastasis. 3) 55-year-old woman who had a Whipple procedure for symptomatic chronic pancreatitis, with multifocal PanIN-3 on final pathology. The patient underwent completion pancreatectomy due to symptomatology and her high-risk profile, with final pathology confirming multifocal PanIN-3. Conclusion: Multifocal high-grade dysplastic lesions of the pancreas might benefit from surgical resection.
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Affiliation(s)
- Mazhar Soufi
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana University Health, Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, Indiana
| | - Michele T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana University Health, Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, Indiana.,Indiana University Cancer Center, Indianapolis, Indiana
| | - Rosalie A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana University Health, Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, Indiana
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana University Health, Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, Indiana
| | - Howard H Wu
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Christian Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana University Health, Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, Indiana.,Indiana University Cancer Center, Indianapolis, Indiana.,Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana.,Walther Oncology Center, Indianapolis, Indiana
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159
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Persaud A, Kakked G, Ahmed A, Shulik O, Ahlawat S. Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy. J Surg Res 2019; 241:95-102. [PMID: 31018171 DOI: 10.1016/j.jss.2019.03.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD. MATERIALS AND METHODS The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay. RESULTS A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014. CONCLUSIONS Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.
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Affiliation(s)
- Alana Persaud
- Division of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Gaurav Kakked
- Division of Medicine, Mount Sinai West, New York, New York
| | - Ahmed Ahmed
- Division of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Oleg Shulik
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sushil Ahlawat
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
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160
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Mackay TM, Wellner UF, van Rijssen LB, Stoop TF, Busch OR, Groot Koerkamp B, Bausch D, Petrova E, Besselink MG, Keck T, van Santvoort HC, Molenaar IQ, Kok N, Festen S, van Eijck CHJ, Bonsing BA, Erdmann J, de Hingh I, Buhr HJ, Klinger C. Variation in pancreatoduodenectomy as delivered in two national audits. Br J Surg 2019; 106:747-755. [DOI: 10.1002/bjs.11085] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractBackgroundNationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.MethodsAnonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.ResultsOverall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.ConclusionThis comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.
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Affiliation(s)
- T M Mackay
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - U F Wellner
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - L B van Rijssen
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T F Stoop
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - D Bausch
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - E Petrova
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T Keck
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - H C van Santvoort
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - I Q Molenaar
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - N Kok
- Antoni van Leeuwenhoek Hospital, Amsterdam
| | | | | | | | - J Erdmann
- Leiden University Medical Centre, Leiden
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161
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Klein F, Pelzer U, Schmuck RB, Malinka T, Felsenstein M, Denecke T, Pratschke J, Bahra M. Strengths, Weaknesses, Opportunities, and Threats of Centralized Pancreatic Surgery: a Single-Center Analysis of 3000 Consecutive Pancreatic Resections. J Gastrointest Surg 2019; 23:492-502. [PMID: 30187320 DOI: 10.1007/s11605-018-3867-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic surgery at high-volume centers has undergone major changes over the last decades. However, the quality of surgery remains to be considered as one important factor for achieving long-term survival especially in patients at advanced stages of disease. METHODS Between January 1990 and June 2017, 3000 consecutive patients have undergone pancreatic resections at our institution. Relevant postoperative data and histopathological findings as well as overall survival were analyzed. In addition, a SWOT (strengths, weaknesses, opportunities, threats) analysis of pancreatic surgery at high-volume centers was performed. RESULTS A total of 2218 pancreatic head resections (74%), 494 distal pancreatectomies (16%), 200 total pancreatectomies (7%), and 88 other resections (3%) were performed within our study period. Despite additional vascular resections in 265 patients (9%) and additional liver resections in 167 patients (6%), overall perioperative mortality did not exceed 3%. Overall survival strongly depended on the underlying disease, as well as on lymph node stage (p = < 0.001) and surgical radicality (p = < 0.001). CONCLUSIONS The decentralization of pancreatic surgery over the last decades has led to a focus on high-volume centers to perform extended procedures in complex patients. The present SWOT analysis underlines the significance of a centralization of pancreatic surgery for patient safety and to increase the chance of long-term survival.
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Affiliation(s)
- Fritz Klein
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rosa Bianca Schmuck
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marcus Bahra
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Fernández Del Castillo C. Safe surgery for cystic tumors of the pancreas. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:85-86. [PMID: 30746958 DOI: 10.17235/reed.2019.6042/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cystic tumors of the pancreas are a common indication for pancreatic surgery, and many of them are incidentally-discovered. Some of these tumors are malignant, and many others are pre-malignant. Less than two generations ago, pancreatic surgery was risky business. Surgical mortality, even in some of the best institutions in the world, was about 25%. Complications were very common and not infrequently patients required reoperations and had to remain in the hospital for weeks or even months. They emerged from this highly debilitated, and often went on to have a very poor quality of life. Not surprisingly, for these reasons, pancreatic resection was used only as a "last resort", and mostly for cancer.
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Perrotta de Souza LM, Moreira JP, Fogaça HS, Eulálio JMR, Luiz RR, de Souza HS. Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis. Hepatobiliary Pancreat Dis Int 2019; 18:79-86. [PMID: 30583855 DOI: 10.1016/j.hbpd.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years. METHODS Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics. RESULTS A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015. CONCLUSIONS This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.
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Affiliation(s)
- Lucila M Perrotta de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jessica Pl Moreira
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Homero S Fogaça
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Marcus Raso Eulálio
- Department of Surgery, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronir R Luiz
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Heitor Sp de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
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164
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Lessing Y, Pencovich N, Nevo N, Lubezky N, Goykhman Y, Nakache R, Lahat G, Klausner JM, Nachmany I. Early reoperation following pancreaticoduodenectomy: impact on morbidity, mortality, and long-term survival. World J Surg Oncol 2019; 17:26. [PMID: 30704497 PMCID: PMC6357503 DOI: 10.1186/s12957-019-1569-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/23/2019] [Indexed: 02/08/2023] Open
Abstract
Background Reoperation following PD is a surrogate marker for a complex post-operative course and may lead to devastating consequences. We evaluate the indications for early reoperation following PD and analyze its effect on short- and long-term outcome. Methods Four hundred and thirty-three patients that underwent PD between August 2006 and June 2016 were retrospectively analyzed. Results Forty-eight patients (11%; ROp group) underwent 60 reoperations within 60 days from PD. Forty-two patients underwent 1 reoperation, and 6 had up to 6 reoperations. The average time to first reoperation was 10.1 ± 13.4 days. The most common indications were anastomotic leaks (22 operations in 18 patients; 37.5% of ROp), followed by post-pancreatectomy hemorrhage (PPH) (14 reoperations in 12 patients; 25%), and wound complications in 10 (20.8%). Patients with cholangiocarcinoma had the highest reoperation rate (25%) followed by ductal adenocarcinoma (12.3%). Reoperation was associated with increased length of hospital stay and a high post-operative mortality of 18.7%, compared to 2.6% for the non-reoperated group. For those who survived the post-operative period, the overall and disease-free survival were not affected by reoperation. Conclusions Early reoperations following PD carries a dramatically increased mortality rate, but has no impact on long-term survival.
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Affiliation(s)
- Yonatan Lessing
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel.
| | - Niv Pencovich
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nir Lubezky
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Yaacov Goykhman
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Richard Nakache
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Guy Lahat
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Joseph M Klausner
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
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165
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Endo A, Shiraishi A, Otomo Y, Fushimi K, Murata K. Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database. J Intensive Care 2019; 7:7. [PMID: 30733868 PMCID: PMC6354429 DOI: 10.1186/s40560-019-0363-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care. Methods We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed. Results We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results. Conclusions Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results. Electronic supplementary material The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akira Endo
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Atsushi Shiraishi
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan.,2Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba Japan
| | - Yasuhiro Otomo
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Kiyohide Fushimi
- 3Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Murata
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan.,The Shock Trauma and Emergency Medical Center, Matsudo City General Hospital, 933-1 Sendabori,, Matsudo, Chiba Japan
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166
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Rezende AQDM, Dutra JPS, Gestic MA, Utrini MP, Callejas-Neto F, Chaim EA, Cazzo E. PANCREATICODUODENECTOMY: IMPACT OF THE TECHNIQUE ON OPERATIVE OUTCOMES AND SURGICAL MORTALITY. ACTA ACUST UNITED AC 2019; 32:e1412. [PMID: 30624521 PMCID: PMC6323629 DOI: 10.1590/0102-672020180001e1412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. AIM To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. METHOD Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. RESULTS Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). CONCLUSION There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.
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Affiliation(s)
| | - João Paulo Simões Dutra
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Martinho Antonio Gestic
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Murillo Pimentel Utrini
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Francisco Callejas-Neto
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Elinton Adami Chaim
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Everton Cazzo
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
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167
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Paiella S, De Pastena M, Romeo F, D'onofrio M, Fontana M, Pea A, De Marchi G, Crinò SF, Bassi C, Salvia R. Ablation treatments in unresectable pancreatic cancer. MINERVA CHIR 2019; 74:263-269. [PMID: 30600963 DOI: 10.23736/s0026-4733.18.07881-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Ablation treatments have been increasingly applied as an alternative treatment for unresectable locally advanced pancreatic cancer (LAPC). The goal of LAPC therapy is surgical resection with negative margins (R0); however, that can be achieved only in a minority of patients and only following neoadjuvant treatment. Ablation might be useful for those patients with unresectable LAPC that do not progress towards metastatic stage and do not experience a true downstaging. Indeed, some LAPC that tend to grow locally, might be the subgroup of tumors that could benefit from ablation. Experience is necessary to select patients and the technique to adopt, since serious or fatal complications can occur. This review aims to discuss the role of ablation treatments in LAPC, with a unique focus on radiofrequency ablation and irreversible electroporation.
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Affiliation(s)
- Salvatore Paiella
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy -
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Francesco Romeo
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Mirko D'onofrio
- Unit of Radiology, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Martina Fontana
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Giulia De Marchi
- Unit of Gastroenterology B, Pancreas Institute, Policliclino GB Rossi, University of Verona, Verona, Italy
| | - Stefano F Crinò
- Unit of Gastroenterology and Digestive Endoscopy, Pancreas Institute, Policliclino GB Rossi, University of Verona, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Pancreas Institute, Policlinico GB Rossi, University of Verona, Verona, Italy
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168
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Kennedy HG, Simpson A, Haque Q. Perspective On Excellence in Forensic Mental Health Services: What We Can Learn From Oncology and Other Medical Services. Front Psychiatry 2019; 10:733. [PMID: 31681042 PMCID: PMC6813277 DOI: 10.3389/fpsyt.2019.00733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/12/2019] [Indexed: 12/11/2022] Open
Abstract
We propose that excellence in forensic and other mental health services can be recognized by the abilities necessary to conduct randomized controlled trials (RCTs) and equivalent forms of rigorous quantitative research to continuously improve the outcomes of treatment as usual (TAU). Forensic mental health services (FMHSs) are growing, are high cost, and increasingly provide the main access route to more intensive, organized, and sustained pathways through care and treatment. A patient newly diagnosed with a cancer can expect to be enrolled in RCTs comparing innovations with the current best TAU. The same should be provided for patients newly diagnosed with severe mental illnesses and particularly those detained and at risk of prolonged periods in a secure hospital. We describe FMHSs in four levels 1 to 4, basic to excellent, according to seven domains: values or qualities, clinical organization, consistency, timescale, specialization, routine outcome measures, and research. Excellence is not elitism. Not all centers need to achieve excellence, though all should be of high quality. Services can provide each population with a network of centers with access to one center of excellence. Excellence is the standard needed to drive the virtuous circle of research and development that is necessary for teaching, training, and the pursuit of new knowledge and better outcomes. Substantial advances in treatment of severe mental disorders require a drive at a national and international level to create services that meet these standards of excellence and are focused, active, and productive to drive better functional outcomes for service users.
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Affiliation(s)
- Harry G Kennedy
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.,National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
| | - Alexander Simpson
- Division for Forensic Psychiatry-University of Toronto Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Quazi Haque
- Elysium Healthcare, London, United Kingdom.,Division for Forensic Psychiatry-University of Toronto Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health-University of Toronto, Toronto, ON, Canada
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169
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Latchana N, Davis L, Coburn NG, Mahar A, Liu Y, Hammad A, Kagedan D, Elmi M, Siddiqui M, Earle CC, Hallet J. Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma. BJS Open 2018; 3:85-94. [PMID: 30734019 PMCID: PMC6354229 DOI: 10.1002/bjs5.50115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution. Methods This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders. Results Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km). Conclusion After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.
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Affiliation(s)
- N Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Davis
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - N G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Y Liu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Hammad
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of General Surgery, Mansoura University, Mansoura, Egypt
| | - D Kagedan
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - M Elmi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - M Siddiqui
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - C C Earle
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - J Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
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170
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Effect of Institutional Case Volume on In-Hospital Mortality After Deceased Donor Liver Transplantation: A Nationwide Retrospective Cohort Study in Korea. Transplant Proc 2018; 50:3644-3649. [DOI: 10.1016/j.transproceed.2018.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/09/2018] [Indexed: 12/25/2022]
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171
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Seo HK, Hwang DW, Park SY, Park Y, Lee SJ, Lee JH, Song KB, Lee YJ, Kim SC. The survival impact of surgical waiting time in patients with resectable pancreatic head cancer. Ann Hepatobiliary Pancreat Surg 2018; 22:405-411. [PMID: 30588533 PMCID: PMC6295371 DOI: 10.14701/ahbps.2018.22.4.405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/26/2022] Open
Abstract
Backgrounds/Aims After centralization policy, clinical outcomes have been improved in patients underwent pancreaticoduodenectomy for pancreatic cancer. However, centralization could exacerbate the prolongation of surgical waiting time. This study aims to investigate whether the shorter waiting time correlates with the better survival and to identify the major confounders that influence the association between those. Methods In this retrospective cohort study, a total 554 patients with pathologically confirmed pancreatic ductal adenocarcinoma were assessed the eligibility from 2014 through 2015. Patients with neoadjuvant chemotherapy, body-tail resection, total pancreatectomy and combined adjacent organ resection were excluded. All patients were divided into two groups by median waiting time, 21 days, defined as the date difference between initial imaging diagnosis and operation. Results Median overall survival did not differ between long and short waiting group (30.4 vs 24.8 months, p=0.35; HR=0.84, 95% CI=0.58-1.21). The proportion of cancer stage shifting, the difference between clinical and pathologic staging, did not differ depending on waiting time group (p=0.811 and 0.255, each of reviewers). Short waiting time was highly correlated with high initial clinical stage (Spearman correlation coefficients -0.201 (p=0.006) and -0.100 (p=0.175), each of reviewers). Conclusions Initial clinical stage had confounding effect on the association between waiting time and overall survival. Therefore, in evaluating centralization policy at the national level, evidence for maximum acceptable waiting time should be investigated in the near future with considering that surgical waiting time could be affected by initial clinical stage.
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Affiliation(s)
- Hye Kyoung Seo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jae Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Joo Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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172
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Mortality and morbidity after pancreatoduodenectomy in patients undergoing hemodialysis: Analysis using a national inpatient database. Surgery 2018; 165:747-750. [PMID: 30424925 DOI: 10.1016/j.surg.2018.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after pancreatoduodenectomy remains unknown. METHODS We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify patients who underwent pancreatoduodenectomy from July 2010 to March 2015. We conducted propensity-score-matching analyses to compare the outcomes, including postoperative complications and 30- and 90-day mortality after pancreatoduodenectomy between patients with and without hemodialysis. RESULTS Of 30,495 eligible patients, 307 (1.0%) received hemodialysis. In the unmatched cohort, the proportions of male sex, younger age, pancreatic cancer, ischemic heart disease, diabetes mellitus, and hypertension were greater in patients with hemodialysis than those without hemodialysis. A 1-to-4 propensity score matching created a total of 1,535 patients, including 307 with hemodialysis and 1,228 without hemodialysis. Patients undergoing hemodialysis had greater proportions of postoperative complications, including peritonitis (8.8% vs 4.8%, P = .012), sepsis or disseminated intravascular coagulation (3.6% vs 0.7%, P = .001), intra-abdominal bleeding (4.9% vs 0.7%, P < .001), and acute coronary event (4.2% vs 1.7%, P = .015). Propensity score matching showed that patients undergoing hemodialysis had an increased risk of postoperative complications (OR, 1.62; 95% CI, 1.23-2.14; P = .001), 30-day mortality (OR, 7.45; 95% CI, 3.26-17.0; P < .001), and 90-day mortality (OR, 10.9; 95% CI, 6.58-18.2; P < .001) than those not undergoing hemodialysis. CONCLUSION Patients undergoing hemodialysis had a significantly increased risk of postoperative complications and death after pancreatoduodenectomy. In particular, surgeons should consider the increased risk of intra-abdominal bleeding, peritonitis, sepsis or disseminated intravascular coagulation, and acute coronary event in patients with hemodialysis.
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173
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Bateni SB, Olson JL, Hoch JS, Canter RJ, Bold RJ. Drivers of Cost for Pancreatic Surgery: It's Not About Hospital Volume. Ann Surg Oncol 2018; 25:3804-3811. [PMID: 30218244 DOI: 10.1245/s10434-018-6758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status. METHODS We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing ≥ 19 operations annually. RESULTS The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [- $1175, 95% confidence interval (CI) - $3254 to $904, p = 0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (- $99, 95% CI - $1612 to 1414, p = 0.90), one or more adverse outcomes (- $1586, 95% CI - $4771 to 1599, p = 0.33), or one or more complications (- $2835, 95% CI - $7588 to 1919, p = 0.24). CONCLUSIONS While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jennifer L Olson
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Robert J Canter
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Richard J Bold
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA.
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Hachey K, Morgan R, Rosen A, Rao SR, McAneny D, Tseng J, Doherty G, Sachs T. Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes After Pancreaticoduodenectomy. Ann Surg Oncol 2018; 25:3795-3803. [DOI: 10.1245/s10434-018-6732-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Indexed: 02/06/2023]
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175
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Merath K, Bagante F, Chen Q, Beal EW, Akgul O, Idrees J, Dillhoff M, Cloyd J, Schmidt C, Pawlik TM. The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis. J Gastrointest Surg 2018; 22:1538-1548. [PMID: 29736663 DOI: 10.1007/s11605-018-3783-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/12/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Decreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery. METHODS The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4-5 days), routine discharge (6-9 days), and late discharge (10-14 days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission. RESULTS A total of 28,114 patients underwent HPB procedures. Overall median LOS was 7 days (IQR 5-11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011-4% (OR 1.04, 95% CI 0.96-1.15) vs. 2012-10% (OR 1.10, 95% CI 1.01-1.20) vs. 2013-21% (OR 1.21, 95% CI 1.11-1.32) vs. 2014-32% (OR 1.32, 95% CI 1.21-1.44)) (p < 0.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all p < 0.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (p < 0.001). Among patients readmitted within 90 days, in-hospital mortality was similar among patients who had early (n = 43, 2.4%) versus routine discharge (n = 65, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge ($54,476 [IQR 40,053-79,100] vs. $75,192 [IQR 53,296-113,123] vs. $115,061 [IQR 79,162-171,077], respectively) (p < 0.001). CONCLUSIONS Early discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jay Idrees
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Leeds IL, Pronovost PJ, Austin JM, Haut ER. Value-based purchasing may unfairly penalize specialty centers performing combined liver–colon multivisceral resections. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2018. [DOI: 10.1177/2516043518790654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Some of the measures in value-based purchasing programs may be flawed due to inadequate risk adjustment. The purpose of this study was to examine the effect of the surgical casemix on surgical site infection rates using combined colectomy–hepatectomy resections as a test case. Methods We identified all adult patients undergoing elective colon surgery (2007–2013) in the National Inpatient Sample. We defined patients with a concurrent liver resection as “multivisceral resections.” Cases from each hospital were pooled by hospital identifier. The association between surgical site infection rate and the proportion of multivisceral resections performed was compared statistically. Findings were further tested for independence against hospital-level characteristics similar to risk-adjusted surgical site infection rate reporting. Results We identified 1014 hospitals performing 127,646 colon surgeries including 1168 (0.9%) multivisceral resections. The overall surgical site infection rate for multivisceral resection was 11.3% versus 1.6% for colectomy-only resections (p < 0.001). Simple linear regression demonstrated a 2.3% increase in a hospital’s surgical site infection rate for each 1% increase in the proportion of multivisceral resections performed. Multivariable linear regression demonstrated a preserved association. Conclusion A hospital’s rate of surgical site infections is positively associated with the proportion of multivisceral resections performed. Value-based purchasing programs should assess readily available data for further risk-adjustment inclusion.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - J Matthew Austin
- Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bartolini I, Bencini L, Risaliti M, Ringressi MN, Moraldi L, Taddei A. Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation. Gastroenterol Res Pract 2018; 2018:9647247. [PMID: 30140282 PMCID: PMC6081603 DOI: 10.1155/2018/9647247] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/29/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023] Open
Abstract
Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.
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Affiliation(s)
- Ilenia Bartolini
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Lapo Bencini
- Department of Oncology, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Matteo Risaliti
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Maria Novella Ringressi
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Luca Moraldi
- Department of Oncology, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Antonio Taddei
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
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Goretzki PE, Mogl MT, Akca A, Pratschke J. Curative and palliative surgery in patients with neuroendocrine tumors of the gastro-entero-pancreatic (GEP) tract. Rev Endocr Metab Disord 2018; 19:169-178. [PMID: 30280290 DOI: 10.1007/s11154-018-9469-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The incidence of neuroendocrine tumors (NET) increases with age. Lately, the diagnosis of NET was mainly caused by early detection of small NET (<1 cm) in the rectum and stomach, which are depicted by chance during routine and prophylactic endoscopy. Also in patients with large and metastatic pancreatic and intestinal tumors thorough pathologic investigation with use of different immunohistologic markers discovers more neuroendocrine tumors with low differentiation grade (G2-G3) and more neuroendocrine carcinomas (NEC), nowadays, than in former times. While gastric and rectal NET are discovered as small (<1 cm in diameter) and mainly highly differentiated tumors, demonstrating lymph node metastases in less than 10% of the patients, the majority of pancreatic and small bowel NET have already metastasized at the time of diagnosis. This is of clinical importance, since tumor stage and differentiation grade not only influence prognosis but also surgical procedure and may define whether a combination of surgery with systemic biologic therapy, chemotherapy or local cytoreductive procedures may be used. The indication for surgery and the preferred surgical procedure will have to consider personal risk factors of each patient (i.e. general health, additional illnesses, etc.) and tumor specific factors (i.e. tumor stage, grade of differentiation, functional activity, mass and variety of loco regional as well as distant metastases etc.). Together they define, whether radical curative or only palliative surgery can be applied. Altogether surgery is the only cure for locally advanced NET and helps to increase quality of life and overall survival in many patients with metastatic neuroendocrine tumors. The question of cure versus palliative therapy sometimes only can be answered with time, however. Many different aspects and various questions concerning the indication and extent of surgery and the best therapeutic procedure are still unanswered. Therefore, a close multidisciplinary cooperation of colleagues involved in biochemical and localization diagnostics and those active in various treatment areas is warranted to search for the optimal strategy in each individual patient. How far genetic screening impacts survival remains to be seen. Since surgeons do have a central role in the treatment of NET patients, they have to understand the need for integration into such an interdisciplinary team.
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Affiliation(s)
- Peter E Goretzki
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
- Leiter Arbeitsbereich endokrine Chirurgie, Chirurgische Klinik, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Martina T Mogl
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Aycan Akca
- Surgical Clinic 1, Lukaskrankenhaus Neuss, Preußenstrasse 84, 41456, Neuss, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
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179
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Stabilini C, Cavallaro G, Bocchi P, Campanelli G, Carlucci M, Ceci F, Crovella F, Cuccurullo D, Fei L, Gianetta E, Gossetti F, Greco DP, Iorio O, Ipponi P, Marioni A, Merola G, Negro P, Palombo D, Bracale U. Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences. Int J Surg 2018; 54:222-235. [PMID: 29730074 DOI: 10.1016/j.ijsu.2018.04.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/06/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.
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Affiliation(s)
| | | | | | | | - Michele Carlucci
- Department of General and Emergency Surgery, IRCCS San Raffaele, Milan, Italy
| | - Francesca Ceci
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | | | - Diego Cuccurullo
- Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Landino Fei
- Department of Anaesthesiological, Surgical and Emergency Sciences, Second University of Naples, Italy
| | - Ezio Gianetta
- Department of Surgical Sciences, University of Genoa, Italy
| | | | | | - Olga Iorio
- General Surgery Unit, Aprilia Hospital, Aprilia (RM), Italy
| | - Pierluigi Ipponi
- General Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Giovanni Merola
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
| | - Paolo Negro
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Denise Palombo
- Department of Surgical Sciences, University of Genoa, Italy
| | - Umberto Bracale
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
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180
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Mathen SJ, Nosrati NN, Merrell GA. Decreased Rate of Complications in Carpal Tunnel Release with Hand Fellowship Training. J Hand Microsurg 2018; 10:26-28. [PMID: 29706733 DOI: 10.1055/s-0037-1618913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 11/19/2017] [Indexed: 10/17/2022] Open
Abstract
Purpose In many procedures, both high case volumes and fellowship training have been shown to improve outcomes. One of the most common procedures performed by hand surgeons, the carpal tunnel release (CTR) is also performed by several other specialties without specialty training in a hand fellowship. This study analyzed the effect that hand fellowship training has on outcomes of CTRs. Materials and Methods Using the American Board of Orthopedic Surgeons (ABOS) Part II candidates' case list submissions, a database was created for all open and endoscopic CTRs. Surgeon training, demographics, technique, and complications were recorded. Complications were then categorized and broken down by technique. Results were then analyzed for statistical significance. Results A total of 29,916 cases were identified. Hand fellowship-trained surgeons performed six times more CTRs at 31 cases per surgeon compared with five for non-hand fellowship-trained surgeons. They also improved outcomes in rates of infection, wound dehiscence, and overall complications. Rates of nerve injury or recurrence showed no statistical difference. This held true for the open release subset. Endoscopically, fellowship-trained surgeons had only improved rates of overall complications. Conclusion Surgeons undergoing additional hand fellowship training may show improved outcomes in the surgical treatment of carpal tunnel syndrome. However, no effect was seen on nerve injury or recurrence of symptoms.
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Affiliation(s)
- Santosh J Mathen
- The Indiana Hand to Shoulder Center, Indianapolis, Indiana, United States
| | - Naveed N Nosrati
- Division of Plastic Surgery, Indiana University, Indianapolis, Indiana, United States
| | - Gregory A Merrell
- The Indiana Hand to Shoulder Center, Indianapolis, Indiana, United States
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181
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Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany. Ann Surg 2018; 267:411-417. [DOI: 10.1097/sla.0000000000002248] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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182
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Prognostic Impact of Bacterobilia on Morbidity and Postoperative Management After Pancreatoduodenectomy: A Systematic Review and Meta-analysis. World J Surg 2018; 42:2951-2962. [DOI: 10.1007/s00268-018-4546-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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183
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Revishvili AS, Kriger AG, Vishnevsky VA, Smirnov AV, Berelavichus SV, Gorin DS, Akhtanin EA, Kaldarov AR, Raevskaya MB, Zakharova MA. [Current issues in pancreatic surgery]. Khirurgiia (Mosk) 2018:5-14. [PMID: 30307415 DOI: 10.17116/hirurgia20180915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
AIM To present own experience of pancreatic surgery and to analyze literature data for this issue. MATERIAL AND METHODS We have analyzed work of abdominal surgery department over the last 5 years. Moreover, MEDLINE and RSCI databases regarding surgical treatment of pancreatic diseases were assessed. RESULTS There were 456 pancreatectomies. Postoperative complications arose in 176 (38.6%) patients, 11 patients died (2.4%). According to world data, mortality after pancreatectomy reaches 10%. Only creation of specialized centers is proven way to improve the outcomes. CONCLUSION Current medical assistance for pancreatic disease may be only achieved in specialized centers with large number of various pancreatic procedures. The organization of such centers is required throughout the country and certain accreditation criteria should be developed for this purpose. Targeted routing of patients to specialized pancreatology centers will be able to reduce incidence of diagnostic, tactical and technical errors.
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Affiliation(s)
- A Sh Revishvili
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - V A Vishnevsky
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A V Smirnov
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - S V Berelavichus
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - D S Gorin
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - E A Akhtanin
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A R Kaldarov
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - M B Raevskaya
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - M A Zakharova
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
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Thornblade LW, Arbabi S, Flum DR, Qiu Q, Fawcett VJ, Davidson GH. Facility-Level Factors and Outcomes After Skilled Nursing Facility Admission for Trauma and Surgical Patients. J Am Med Dir Assoc 2018; 19:70-76.e1. [PMID: 29042263 PMCID: PMC5742547 DOI: 10.1016/j.jamda.2017.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/04/2017] [Accepted: 08/09/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients discharged to skilled nursing facilities (SNFs) have worse outcomes than those discharged to home, but whether this is due to differences in facility-level factors in addition to patient characteristics is not known. We aimed to determine whether SNF-level factors including nurse staffing and patient density are associated with outcomes after acute hospitalization for trauma or surgery. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Retrospective study of patients discharged to Medicare-certified SNFs after trauma or major surgery from 2007 to 2009. We measured the ratio of beds per nurse and the proportion of trauma and surgery patients at each facility (density). Outcomes were 1-year mortality, hospital readmission, and failure to discharge home at first discharge disposition. RESULTS For 389,133 patients (mean age 78 years, 63% female) admitted to 3707 SNFs, mortality was 26%, hospital readmission 26%, and failure to discharge home 44%. After adjusting for patient-level factors, SNFs with fewer beds per nurse had lower odds of mortality [odds ratio (OR): trauma 0.84; (95% confidence interval: 0.77-0.91), surgery 0.80 (0.75-0.86)], readmission [OR: trauma 0.81 (0.74-0.88), surgery 0.71 (0.65-0.76)], and failure to discharge home [OR: trauma 0.82 [0.74-0.91], surgery 0.66 [0.60-0.72]). SNFs with greater density of specialty patients (>4.3% surgery, >14.1% trauma) had lower odds of readmission [OR: trauma 0.59 (0.53-0.66), surgery 0.62 (0.58-0.67)] and failure to discharge home [OR: trauma 0.48 (0.43-0.55), surgery 0.45 (0.42-0.49)]. CONCLUSIONS There are modifiable SNF-level factors that influence long-term outcomes and may be targets for intervention. Staffing standardization and SNF specialization may reduce variation of quality in post-acute care.
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Affiliation(s)
- Lucas W Thornblade
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA.
| | - Saman Arbabi
- Department of Surgery, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
| | - Qian Qiu
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
| | - Vanessa J Fawcett
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
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Wolk S, Grützmann R, Rahbari NN, Hoffmann RT, Plodeck V, Weitz J, Welsch T, Distler M. Management of clinically relevant postpancreatectomy hemorrhage (PPH) over two decades - A comparative study of 1 450 consecutive patients undergoing pancreatic resection. Pancreatology 2017; 17:943-950. [PMID: 29111264 DOI: 10.1016/j.pan.2017.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/13/2017] [Accepted: 10/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES PPH is the main cause of mortality (up to 50%) after pancreatic resection. Due to differences in time of onset, localization and clinical impairment, there is no consistent management algorithm. METHODS Between 1994 and 2014 the occurrence of PPH in 115 out of 1 450 patients from a prospectively collected database was analyzed. The cohort was divided into two time periods: 1994-2009 and 2010-2014. The differences between the two groups were analyzed. RESULTS The overall incidence of PPH was 7.9%. The main causes of hemorrhage were the pancreatic anastomosis (31.1%) and the splanchnic arteries (23.5%). In the first period, there were more anastomotic hemorrhages (40.0% vs. 20.4%, p = 0.02), while in the second period more hemorrhages from the splanchnic arteries occurred (12.3% vs. 37%, p = 0.002). Bleeding control was achieved by relaparotomy (45.7%), noninterventionally (22.8%), endoscopically (19.7%) and angiographically (13.4%). In the second period, the relevance of interventional angiography significantly increased (24.6% vs. 4.3%, p = 0.001), whereas endoscopy lost importance (7% vs. 30%, p = 0.001). The in-hospital case fatality rate after PPH was 27.4%, with higher case fatality rate following extraluminal hemorrhage (23.9% vs. 3.4%, p < 0.001). CONCLUSIONS A shift in the management of PPH could be seen over the two periods. Interventional angiography has gained more importance in the treatment of severe extraluminal hemorrhage of the splanchnic arteries. Adequate treatment of PPH is crucial to improve the outcome.
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Affiliation(s)
- Steffen Wolk
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Robert Grützmann
- Department of Surgery, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Nuh N Rahbari
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Ralf T Hoffmann
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Verena Plodeck
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marius Distler
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany.
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188
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Wilhelm A, Galata C, Beutner U, Schmied BM, Warschkow R, Steffen T, Brunner W, Post S, Marti L. Duodenal localization is a negative predictor of survival after small bowel adenocarcinoma resection: A population-based, propensity score-matched analysis. J Surg Oncol 2017; 117:397-408. [DOI: 10.1002/jso.24877] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/09/2017] [Accepted: 09/18/2017] [Indexed: 12/12/2022]
Affiliation(s)
| | - Christian Galata
- Department of Surgery; Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg; Mannheim Germany
| | - Ulrich Beutner
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
| | - Bruno M. Schmied
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
- Institute of Medical Biometry and Informatics; University of Heidelberg; Heidelberg Germany
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
| | - Walter Brunner
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
| | - Stefan Post
- Department of Surgery; Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg; Mannheim Germany
| | - Lukas Marti
- Department of Surgery; Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg; Mannheim Germany
- Department of General, Visceral, Endocrine and Transplantation Surgery; Kantonsspital St. Gallen; St. Gallen Switzerland
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189
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Kreindler SA, Siragusa L, Bohm E, Rudnick W, Metge CJ. Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes. Can J Surg 2017; 60:349-354. [PMID: 28930037 DOI: 10.1503/cjs.000517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Timely access to orthopedic trauma surgery is essential for optimal outcomes. Regionalization of some types of surgery has shown positive effects on access, timeliness and outcomes. We investigated how the consolidation of orthopedic surgery in 1 Canadian health region affected patients requiring hip fracture surgery. METHODS We retrieved administrative data on all regional emergency department visits for lower-extremity injury and all linked inpatient stays from January 2010 through March 2013, identifying 1885 hip-fracture surgeries. Statistical process control and interrupted time series analysis controlling for demographics and comorbidities were used to assess impacts on access (receipt of surgery within 48-h benchmark) and surgical outcomes (complications, in-hospital/30-d mortality, length of stay). RESULTS There was a significant increase in the proportion of patients receiving surgery within the benchmark. Complication rates did not change, but there appeared to be some decrease in mortality (significant at 6 mo). Length of stay increased at a hospital that experienced a major increase in patient volume, perhaps reflecting challenges associated with patient flow. CONCLUSION Regionalization appeared to improve the timeliness of surgery and may have reduced mortality. The specific features of the present consolidation (including pre-existing interhospital performance variation and the introduction of daytime slates at the referral hospital) should be considered when interpreting the findings.
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Affiliation(s)
- Sara A Kreindler
- From the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Kreindler, Bohm, Metge); the George and Fay Yee Centre for Healthcare Innovation, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Kreindler, Bohm, Metge); the College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Siragusa); the Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); the Concordia Hip and Knee Institute, Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); and the St. Boniface Hospital, Winnipeg, Man. (Rudnick)
| | - Lanette Siragusa
- From the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Kreindler, Bohm, Metge); the George and Fay Yee Centre for Healthcare Innovation, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Kreindler, Bohm, Metge); the College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Siragusa); the Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); the Concordia Hip and Knee Institute, Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); and the St. Boniface Hospital, Winnipeg, Man. (Rudnick)
| | - Eric Bohm
- From the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Kreindler, Bohm, Metge); the George and Fay Yee Centre for Healthcare Innovation, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Kreindler, Bohm, Metge); the College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Siragusa); the Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); the Concordia Hip and Knee Institute, Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); and the St. Boniface Hospital, Winnipeg, Man. (Rudnick)
| | - Wendy Rudnick
- From the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Kreindler, Bohm, Metge); the George and Fay Yee Centre for Healthcare Innovation, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Kreindler, Bohm, Metge); the College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Siragusa); the Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); the Concordia Hip and Knee Institute, Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); and the St. Boniface Hospital, Winnipeg, Man. (Rudnick)
| | - Colleen J Metge
- From the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Kreindler, Bohm, Metge); the George and Fay Yee Centre for Healthcare Innovation, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Kreindler, Bohm, Metge); the College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Siragusa); the Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); the Concordia Hip and Knee Institute, Winnipeg Regional Health Authority, Winnipeg, Man. (Bohm); and the St. Boniface Hospital, Winnipeg, Man. (Rudnick)
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190
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Macedo FIB, Jayanthi P, Mowzoon M, Yakoub D, Dudeja V, Merchant N. The Impact of Surgeon Volume on Outcomes After Pancreaticoduodenectomy: a Meta-analysis. J Gastrointest Surg 2017; 21:1723-1731. [PMID: 28744743 DOI: 10.1007/s11605-017-3498-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite significant improvement in operative mortality rates following pancreaticoduodenectomy (PD), morbidity remains high. Outcomes following PD may be improved in high-volume centers and with high-volume surgeons. We sought to evaluate the association between surgeon experience and postoperative outcomes after PD. METHODS An online database search of MEDLINE and EMBASE was performed; key bibliographies were reviewed. Studies comparing operative outcomes of high-volume surgeon (HVS) and low-volume surgeon (LVS) performing PD were included. Odds ratios with the corresponding 95% confidence intervals (CI) by random fixed effects models of pooled data were calculated. Definition of HVS varied among the studies, ranging from 6 to >20 PD/year. The primary endpoint was 30-day mortality, and secondary outcomes were complication rates, length of stay (LOS), hospital costs, and readmission rates. Study quality was assessed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. RESULTS Search strategy yielded 360 publications. Eleven studies met the inclusion criteria comprising 36,449 patients. Among these patients, 12,512 (34.3%) PDs were performed by HVS and 23,937 (65.7%) by LVS. Meta-analysis of included studies showed that HVS had significantly lower mortality rates than LVS (2.4 vs. 6.7%, OR 2.88; 95% CI 2.51-3.27, p < 0.001). They also had significantly lower overall complication rates (36.3 vs. 50.3%, OR 1.71; 95% CI 1.62-1.81, p < 0.001), hospital costs (range $10,818-141,322 vs. $12,114-198,678, OR 0.13; 95% CI 0.07-0.19, p < 0.001), and LOS (range 11-35 vs. 14-38 days, OR 2.86; 95% CI 2.03-3.68, p < 0.001). CONCLUSIONS HVS performing PD have significantly better outcomes than LVS in terms of decreased mortality, morbidity, LOS, and hospital costs. Efforts toward increased regionalization of care should be discussed. Consensus regarding definition of HVS needs to be undertaken.
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Affiliation(s)
- Francisco Igor B Macedo
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA.
| | - Prakash Jayanthi
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA
| | - Mia Mowzoon
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA
| | - Danny Yakoub
- Division of Surgical Oncology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vikas Dudeja
- Division of Surgical Oncology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun Merchant
- Division of Surgical Oncology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA
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191
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Kim EY, Song KY, Lee J. Does Hospital Volume Really Affect the Surgical and Oncological Outcomes of Gastric Cancer in Korea? J Gastric Cancer 2017; 17:246-254. [PMID: 28970955 PMCID: PMC5620094 DOI: 10.5230/jgc.2017.17.e31] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/31/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The significance of hospital volume remains inconsistent and controversial. In particular, few studies have examined whether hospital volume is associated with the outcome of gastrectomy for gastric cancer in East Asia. This study examined the effect of hospital volume on the short-term surgical and long-term oncological outcomes of patients undergoing curative gastrectomy for gastric cancer. MATERIALS AND METHODS Between 2009 and 2011, 1,561 patients underwent curative gastrectomy for gastric cancer at Seoul St. Mary's Hospital (n=1,322) and Bucheon St. Mary's Hospital (n=239). We defined Seoul St. Mary's Hospital as a high-volume center and Bucheon St. Mary's Hospital as a low-volume center. RESULTS The extent of resection, rate of combined resection, tumor stage, operating time, and hospital stay did not differ significantly between the 2 hospitals. In addition, the hospital volume was not significantly associated with the 30-day morbidity and mortality. When the overall and disease-free survival rates of the patients were stratified according to stage, hospital volume was not significantly associated with prognosis at any stage. CONCLUSIONS Hospital volume might not be a decisive factor with respect to the surgical and oncological outcomes of patients if well-trained surgeons perform gastrectomy for gastric cancer.
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Affiliation(s)
- Eun Young Kim
- Department of Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Junhyun Lee
- Department of Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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192
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Hsu RCJ, Salika T, Maw J, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Influence of hospital volume on nephrectomy mortality and complications: a systematic review and meta-analysis stratified by surgical type. BMJ Open 2017; 7:e016833. [PMID: 28877947 PMCID: PMC5588977 DOI: 10.1136/bmjopen-2017-016833] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/22/2017] [Accepted: 06/28/2017] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy. METHODS Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score and most likely to introduce bias from misclassification of standardised hospital volume. RESULTS Some 226 372 patients from 16 publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy.HV hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61 to 0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29 to 0.81, p<0.01), respectively. In addition, radical nephrectomy in HV hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73 to 0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31 to 2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55 to 1.30, p=0.44) was observed for partial nephrectomy. CONCLUSIONS Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by HV hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.
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Affiliation(s)
- Ray C J Hsu
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Theodosia Salika
- Epidemiology of Cancer Healthcare and Outcomes(ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Jonathan Maw
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes(ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James N Armitage
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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193
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Implementation and Evaluation of a Clinical Pathway for Pancreaticoduodenectomy Procedures: a Prospective Cohort Study. J Gastrointest Surg 2017; 21:1428-1441. [PMID: 28589299 DOI: 10.1007/s11605-017-3459-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/16/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Medical and nursing protocols in perioperative care for pancreaticoduodenectomy are mainly mono-disciplinary, limiting their integration and transparency in a continuous health care system. The aims of this study were to evaluate adherence to a multidisciplinary clinical pathway for all pancreaticoduodenectomy patients during their entire hospital stay and to determine if the use of this clinical pathway is associated with beneficial effects on clinical end points. MATERIALS AND METHODS A prospective cohort study was conducted in 95 pancreaticoduodenectomy patients treated according to a clinical pathway, including a variance report, compared to a historical control group (n = 52) with a traditional treatment regime. RESULTS Process evaluation of the clinical pathway group revealed that protocol adherence throughout all units was above 80%. Major complications according to Clavien-Dindo classification grade ≥3 decreased from 27 to 13%; p = 0.02. Hospital length of stay was significantly shorter in the clinical pathway group, median 10 days [IQR 8-15], compared with the control group, median 13 days [IQR 10-18]; p = 0.02. CONCLUSION The use of a clinical pathway in pancreaticoduodenectomy patients was associated with high protocol adherence, improved outcome and shorter hospital length of stay. Variance report analysis and protocol adherence with a Prepare-Act-Reflect Cycle are essential in surveillance of outcome.
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194
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Abstract
OPINION STATEMENT Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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195
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Wellner UF, Keck T. Quality Indicators in Pancreatic Surgery: Lessons Learned from the German DGAV StuDoQ|Pancreas Registry. Visc Med 2017; 33:126-130. [PMID: 28560227 DOI: 10.1159/000456045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Political and public interest in quality management in surgery is increasing. The German Society for General and Visceral Surgery (DGAV) established the DGAV StuDoQ, a nationwide registry for quality assessment in visceral surgery, with the organ-specific module DGAV StuDoQ|Pancreas. The first prerequisite for the measurement of quality is the definition of quality indicators. These can be related to risk factors which are also documented in the registry. METHODS Quality indicators for pancreatic surgery were developed by review of the current literature and expert consensus. After ranking the potential quality indicators, three essential indicators for outcome quality were selected for further review of the literature. Current figures were extracted from the DGAV StuDoQ|Pancreas registry and the correlation with selected risk factors was tested. RESULTS Three essential outcome quality indicators were selected: in-hospital mortality, TV30, and severe complications according to the Clavien-Dindo Classification. Preliminary data confirms the validity of risk factors included in the DGAV StuDoQ|Pancreas registry. CONCLUSION Essential quality indicators were defined for pancreatic surgery. The DGAV StuDoQ|Pancreas constitutes a valid platform for risk-adjusted quality assessment in Germany.
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Affiliation(s)
- Ulrich F Wellner
- Clinic for Surgery, German Society for General and Visceral Surgery (DGAV), Berlin, Germany.,Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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196
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Abstract
Although robot-assisted pancreatic surgery has been considered critically in the past, it is nowadays an established standard technique in some centers, for distal pancreatectomy and pancreatic head resection. Compared with the laparoscopic approach, the use of robot-assisted surgery seems to be advantageous for acquiring the skills for pancreatic, bile duct and vascular anastomoses during pancreatic head resection and total pancreatectomy. On the other hand, the use of the robot is associated with increased costs and only highly effective and professional robotic programs in centers for pancreatic surgery will achieve top surgical and oncological quality, acceptable operation times and a reduction in duration of hospital stay. Moreover, new technologies, such as intraoperative fluorescence guidance and augmented reality will define additional indications for robot-assisted pancreatic surgery.
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Affiliation(s)
- B Müssle
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - M Distler
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - T Welsch
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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197
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Kagedan DJ, Goyert N, Li Q, Paszat L, Kiss A, Earle CC, Karanicolas PJ, Wei AC, Mittmann N, Coburn NG. The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy. J Gastrointest Surg 2017; 21:506-515. [PMID: 28058617 DOI: 10.1007/s11605-016-3346-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. METHODS A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. RESULTS Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers. CONCLUSION Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nik Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Lawrence Paszat
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Alice C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. .,, 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada.
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198
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Hung YN, Liu TW, Wen FH, Chou WC, Tang ST. Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan. Oncologist 2017; 22:460-469. [PMID: 28232596 DOI: 10.1634/theoncologist.2016-0283] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/02/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND No population-based longitudinal studies on end-of-life (EOL) expenditures were found for cancer decedents. METHODS This population-based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient-level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health-specific purchasing power parity conversions to account for different health-purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. RESULTS Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic-pancreatic cancers, and dying within 7-24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. CONCLUSION Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non-U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high-risk patients. The Oncologist 2017;22:460-469Implications for Practice: Cancer-care costs are highest during the end-of-life (EOL) period for cancer decedents. This population-based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL-care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non-U.S. countries surveyed in 2010. To slow the increasing cost of EOL-cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high-risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan, Republic of China
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Graduate School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan, Republic of China
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199
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Younan G, Tsai S, Evans DB, Christians KK. A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It. J Gastrointest Surg 2017; 21:1186-1191. [PMID: 28447199 PMCID: PMC5486682 DOI: 10.1007/s11605-017-3405-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.
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Affiliation(s)
- George Younan
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Susan Tsai
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Douglas B. Evans
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Kathleen K. Christians
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
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200
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Richards MK, Goldin AB, Savinkina A, Doski J, Goldfarb M, Nuchtern J, Langer M, Beierle EA, Vasudevan S, Gow KW, Raval MV. The association between nephroblastoma-specific outcomes and high versus low volume treatment centers. J Pediatr Surg 2017; 52:104-108. [PMID: 27836364 DOI: 10.1016/j.jpedsurg.2016.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Though the volume-outcome relationship has been well-established in adults, low mortality rates and small sample sizes have precluded definitive demonstration in children. This study compares treatment-specific factors for children with nephroblastoma at high (HVC) versus low volume centers (LVC). METHODS We performed a retrospective cohort study comparing patients ≤18years with unilateral nephroblastoma treated at HVCs and LVCs using the National Cancer Data Base (1998-2012). Definitions of HVCs included performing above the median, the upper two quartiles, and the highest decile of nephroblastoma resections. Outcomes included nodal sampling, margin status, time to chemotherapy and radiation, and survival. Statistical analyses included χ2, t-tests, generalized linear, and Cox regression models (p<0.05). RESULTS Of 2911 patients from 210 centers, 1443 (49.6%) were treated at HVCs. There was no difference in frequency of preoperative biopsy or days to radiation (p>0.05). High volume centers were more likely to perform nodal sampling (RR 1.04, 95%CI 1.01-1.08) and had fewer days to chemotherapy (RR 0.80, 95%CI 0.69-0.93). Five-year survival was similar (HVC: 0.93, 95%CI 0.92-0.94; LVC: 0.93, 95%CI 0.91-0.94). CONCLUSIONS HVCs were more likely to perform nodal sampling and had fewer days to chemotherapy. There was no difference in days to radiation or survival between centers. LEVEL OF EVIDENCE Level II (retrospective prognosis study).
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Affiliation(s)
- Morgan K Richards
- University of Washington, Department of Surgery; Seattle Children's Hospital, Department of Thoracic and General Surgery.
| | - Adam B Goldin
- Seattle Children's Hospital, Department of Thoracic and General Surgery
| | | | - John Doski
- Methodist Children's Hospital of South Texas
| | | | | | | | | | | | - Kenneth W Gow
- Seattle Children's Hospital, Department of Thoracic and General Surgery
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