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Schuman AD, Bindal M, Amadio G, Turney AM, Hernandez DJ, Sandulache VC, Liou NE, Wang R, Huang AT. Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer. Laryngoscope 2024. [PMID: 38895890 DOI: 10.1002/lary.31564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/01/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVES Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians. METHODS Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020. RESULTS A total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8-11) to 6 (IQR 5-7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5-8) to 3 (IQR 3-7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7-9) to 5 days (IQR 4.5-7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12-4.89, p = 0.024). CONCLUSION AND RELEVANCE Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Ari D Schuman
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Mohini Bindal
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Grace Amadio
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Anne M Turney
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - David J Hernandez
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - N Eddie Liou
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Ray Wang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Andrew T Huang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
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Quality of Life and Morbidity after Endoscopic Endonasal Skull Base Surgeries Using the Sinonasal Outcomes Test (SNOT): A Tertiary Hospital Experience. Int J Otolaryngol 2021; 2021:6659221. [PMID: 34104196 PMCID: PMC8159648 DOI: 10.1155/2021/6659221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/28/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Endoscopic endonasal skull base surgery (EESBS) has been associated with a minimally invasive and effective approach for pathology of the anterior skull base and associated with less overall morbidity compared with open approaches. However, it is associated with its own potential morbidity related to surgical manipulation or resection of normal and noninflamed intranasal structures to gain adequate access. The assessment of sinonasal QOL (quality of life) postsurgery is therefore a vital aspect in follow-up of these patients. Objectives To assess quality of life and morbidity after endoscopic endonasal skull base surgery using the Sinonasal Outcomes Test (SNOT-22). Methodology. A single-center retrospective cross-sectional review with a sample of 80-100 patients undergoing endoscopic endonasal transsphenoidal surgery was conducted at the ENT and Neurosurgery departments of King Fahad Specialist Hospital-Dammam (KFSH-D) for a period of 10 years from March 2010 to March 2020. Data were collected through hospital records and database, as well as from patients through phone call interviews. Records were reviewed for diagnosis, demographic features, and 22-item Sinonasal Outcomes Test (SNOT-22) scores noted at three points in time: prior to procedure and after, at 3 months and 6 months. Results Within the study cohort comprising 96 patients, the mean age of the participants was 39.5 ± 12.1 years, and diagnostic typing before and after histopathological investigations revealed maximum pituitary adenomas (46.9%) closely followed by CSF-related ailments (41.7%). The changes in the mean and standard deviation of the total SNOT-22 scores postoperatively at the 3rd month (9.5 ± 5.4) and the 6th month (8.8 ± 5.2) were statistically significant (p < 0.001) when compared to the preoperative score (10.8 ± 5.1). Conclusion Although there was a predicted passivity of symptoms in the post-EESBS period, several significant positive outcomes were seen. The increase in discomfort in the sleep domains postsurgery is an issue to pursue and reason out. The overall SNOT-22 scores noted preoperatively and 3 and 6 months postoperatively showed statistically significant improvements in QOL with no long-term effects.
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Windon MJ, Le D, D'Souza G, Bigelow E, Pitman K, Boss E, Eisele DW, Fakhry C. Treatment decision-making among patients with oropharyngeal squamous cell cancer: A qualitative study. Oral Oncol 2021; 112:105044. [PMID: 33130545 PMCID: PMC8556673 DOI: 10.1016/j.oraloncology.2020.105044] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022]
Abstract
Oropharyngeal squamous cell cancer (OPSCC) is now the most common site of head and neck squamous cell cancer. Despite the focus on treatment deintensification in clinical trials, little is known about the preferences, experiences and needs of patients with OPSCC when deciding between surgery and radiation therapy as primary treatment with curative intent. In this qualitative study, pre-treatment and post-treatment oropharyngeal cancer patients were recruited to take part in one-on-one interviews (n = 11 pre-treatment) and focus group discussions (n = 15 post-treatment) about treatment decision-making. Recordings were transcribed and assessed for emergent themes using framework analysis. From the one-on-one interviews and focus group discussions with OPSCC patients, fourteen themes were identified. Participants expressed alarm at diagnosis, decisional conflict, and a variety of roles in decision-making (physician-controlled, shared, and autonomous). Decisions were driven by the perceived recommendation of the treatment team, a desire for physical (surgical) tumor removal, fear of adverse effects of treatment, and patient-specific values. Although participants felt well-informed by their treating physicians, they identified a need for additional patient-centered information. Participants were critical of the poor quality of information available on the internet, and acknowledged the advantage of hearing the experiences of post-treatment patients. The experiences identified herein may be used to guide patient-centered communication during patient counseling and to inform interventions designed to support patients' needs at diagnosis, ultimately helping to implement high-quality, patient-centered care.
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Affiliation(s)
- Melina J Windon
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daisy Le
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elaine Bigelow
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Karen Pitman
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Emily Boss
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - David W Eisele
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carole Fakhry
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Bloomberg~Kimmel Institute for Cancer Immunotherapy, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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4
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Brenner MJ, Chang CWD, Boss EF, Goldman JL, Rosenfeld RM, Schmalbach CE. Patient Safety/Quality Improvement Primer, Part I: What PS/QI Means to Your Otolaryngology Practice. Otolaryngol Head Neck Surg 2019; 159:3-10. [PMID: 29968525 DOI: 10.1177/0194599818779547] [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: 01/22/2023]
Abstract
Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.
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Affiliation(s)
- Michael J Brenner
- 1 School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Emily F Boss
- 3 School of Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Julie L Goldman
- 4 School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Cecelia E Schmalbach
- 6 Roudebush Veterans Medical Center, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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Lang DM, Danan D, Sawhney R, Silver NL, Varadarajan VV, Balamohan S, Bernard SH, Boyce BJ, Dziegielewski PT. Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days. Otolaryngol Head Neck Surg 2019; 160:829-838. [DOI: 10.1177/0194599819835545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Methods Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. Results In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. Discussion DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Implications for Practice Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.
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Affiliation(s)
- Dustin M. Lang
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Deepa Danan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Raja Sawhney
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Natalie L. Silver
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | | | - Sanjeev Balamohan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Stewart H. Bernard
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Brian J. Boyce
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Peter T. Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
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6
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Bowe SN, McCormick ME. Resident and Fellow Engagement in Safety and Quality. Otolaryngol Clin North Am 2019; 52:55-62. [DOI: 10.1016/j.otc.2018.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Cramer JD, Graboyes EM, Brenner MJ. Mortality associated with tracheostomy complications in the United States: 2007-2016. Laryngoscope 2018; 129:619-626. [DOI: 10.1002/lary.27500] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 11/09/2022]
Affiliation(s)
- John D. Cramer
- Department of Otolaryngology-Head and Neck Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Michael J. Brenner
- Department of Otolaryngology-Head and Neck Surgery; University of Michigan; Ann Arbor Michigan U.S.A
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Beswick DM, Smith TL. Improving Value Through Standard and Systematic Data Collection. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0202-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lira RB, Chulam TC, Kowalski LP. Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection. Gland Surg 2018; 7:S42-S52. [PMID: 30175063 DOI: 10.21037/gs.2018.03.04] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection. Methods A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study. Results Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed. Conclusions The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.
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Affiliation(s)
- Renan Bezerra Lira
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Thiago Celestino Chulam
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Luiz Paulo Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
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Ziegler A, Lazzara G, Thorpe E. Safety and Efficacy of Outpatient Parotidectomy. J Oral Maxillofac Surg 2018; 76:2433-2436. [PMID: 29792835 DOI: 10.1016/j.joms.2018.04.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Given the increasing costs of medical care, there has been a shift to outpatient elective surgeries in certain patient populations among all surgical specialties. The goal of this study was to compare the safety and efficacy of outpatient parotidectomy with traditional inpatient parotidectomy. MATERIALS AND METHODS This is a retrospective chart review of all patients who underwent a parotidectomy at a single tertiary academic center from 2007 through 2017. RESULTS There were 568 patients who met the inclusion criteria. There was no difference in demographics or patient comorbidities between the inpatient and outpatient groups. There was no increased incidence of postoperative complications or extent of postoperative care in patients who underwent outpatient parotidectomy. On average at the authors' institution, the direct outpatient parotidectomy cost was $1,200 less than the inpatient equivalent. CONCLUSION Outpatient parotidectomy can be performed safely and cost effectively with no increased risk of complications.
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Affiliation(s)
- Andrea Ziegler
- Resident, Department of Otolaryngology, Loyola University Medical Center, Maywood, IL.
| | - Gina Lazzara
- Medical Student, Stritch School of Medicine, Maywood, IL
| | - Eric Thorpe
- Program Director, Department of Otolaryngology, Loyola University Medical Center, Maywood, IL
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Johnsen NV, Dmochowski RR, Guillamondegui OD. Clinical Utility of Routine Follow-up Cystography in the Management of Traumatic Bladder Ruptures. Urology 2017; 113:230-234. [PMID: 29174624 DOI: 10.1016/j.urology.2017.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate if follow-up cystography alters clinical management in patients after treatment of traumatic bladder ruptures. METHODS Patients with uncomplicated blunt trauma bladder ruptures between 2000 and 2014 were identified in our institutional trauma registry. Primary management strategies consisted of either cystorrhaphy or catheter drainage. Primary outcome analyzed was occurrence of positive follow-up cystogram. Secondary outcomes were use of follow-up cystography and time to negative cystogram. RESULTS One hundred forty patients were identified with a median follow-up of 6.2 months (interquartile range [IQR] 3.0-32.4). Eighty-two patients (58.6%) had extraperitoneal (EP) ruptures, 49 had intraperitoneal (IP) ruptures (35.0%), and 9 had combined EP/IP rupture (6.4%). Fifty-six EP patients were managed with catheter drainage, whereas all other patients underwent cystorrhaphy. Thirty-five cystorrhaphy patients (42%) had no imaging before catheter removal. Forty-nine patients (58%) had cystograms at a median of 15.0 days (IQR 10.0-22.0) after cystorrhaphy, with only 1 patient having a persistent leak. Forty-six catheter drainage EP patients (82%) had negative cystograms at a median of 19.0 days (IQR 15.0-33.0). Of the 10 patients with persistent extravasation, 7 required operations for related complications, whereas 3 had negative imaging at a median of 38.0 days (IQR 25.8-66.8), with a mean of 2.8 cystograms before a negative study. CONCLUSION Follow-up cystography after cystorrhaphy for uncomplicated blunt trauma-associated bladder ruptures rarely, if ever, provides unanticipated clinical information. For catheter drainage EP patients, cystography remains clinically valuable, as at least 18% of patients will have signs of continued extravasation. The optimal timing of cystography and catheter removal remains unknown.
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Affiliation(s)
- Niels Vass Johnsen
- Department of Urology, University of Washington Medical Center, Seattle, WA.
| | - Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Oscar D Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN
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12
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Soler ZM, Jones R, Le P, Rudmik L, Mattos JL, Nguyen SA, Schlosser RJ. Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis. Laryngoscope 2017; 128:581-592. [PMID: 29164622 DOI: 10.1002/lary.27008] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/15/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature. METHODS A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression. RESULTS The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score. CONCLUSIONS Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.
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Affiliation(s)
- Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rabun Jones
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Phong Le
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jose L Mattos
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Shaun A Nguyen
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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13
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Rudmik L, Xu Y, Alt JA, Deconde A, Smith TL, Schlosser RJ, Quan H, Soler ZM. Evaluating Surgeon-Specific Performance for Endoscopic Sinus Surgery. JAMA Otolaryngol Head Neck Surg 2017; 143:891-898. [PMID: 28655057 DOI: 10.1001/jamaoto.2017.0752] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Several identified factors have raised questions concerning the quality of care for endoscopic sinus surgery (ESS), including the presence of large geographic variation in the rates and extent of surgery, poorly defined indications, and lack of ESS-specific quality metrics. Combined with the risk of major complications, ESS represents a high-value target for quality improvement. Objective To evaluate differences in surgeon-specific performance for ESS using a risk-adjusted, 5-year ESS revision rate as a quality metric. Design, Setting, and Participants This retrospective study used a population-based administrative database to study adults (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent primary ESS in Alberta, Canada, between March 1, 2007, and March 1, 2010. The study period ended in 2015 to provide 5 years of follow-up. Interventions Endoscopic sinus surgery for CRS. Main Outcomes and Measures Primary outcomes were the 5-year observed and risk-adjusted ESS revision rate. Logistic regression was used to develop a risk adjustment model for the primary outcome. Results A total of 43 individual surgeons performed primary ESS in 2168 patients with CRS. Within 5 years after the primary ESS procedure, 239 patients underwent revision ESS, and the mean crude 5-year ESS revision rate was 10.6% (range, 2.4%-28.6%). After applying the risk adjustment model and 95% CI to each surgeon, 7 surgeons (16%) had lower-than-expected performance and 2 surgeons (5%) had higher-than-expected performance. Three variables had significant associations with surgeon-specific, 5-year ESS revision rates: presence of nasal polyps (odds ratio [OR], 2.07; 95% CI, 1.59-2.70), more annual systemic corticosteroid courses (OR, 1.33; 95% CI, 1.19-1.48), and concurrent septoplasty (OR, 0.70; 95% CI, 0.55-0.89). Conclusions and Relevance Evaluating surgeon-specific performance for ESS may provide information to assist in quality improvement. Although most surgeons had comparable risk-adjusted, 5-year ESS revision rates, 16% of surgeons had lower-than-expected performance, indicating a potential to improve quality of care. Future studies are needed to evaluate more surgeon-specific variables and validate a risk adjustment model to provide appropriate feedback for quality improvement.
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Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Yuan Xu
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, Rhinology-Sinus and Skull Base Surgery Program, Department of Surgery, University of Utah, Salt Lake City
| | - Adam Deconde
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego
| | - Timothy L Smith
- Division of Rhinology and Sinus/Skull Base Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
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14
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Ciolek PJ, Clancy K, Fritz MA, Lamarre ED. Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction. Am J Otolaryngol 2017; 38:433-437. [PMID: 28476441 DOI: 10.1016/j.amjoto.2017.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/31/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Limited data exists on cardiac complications following head and neck free flaps. DESIGN A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015. RESULTS 368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay. CONCLUSIONS There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.
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15
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Rudmik L, Mattos J, Schneider J, Manes PR, Stokken JK, Lee J, Higgins TS, Schlosser RJ, Reh DD, Setzen M, Soler ZM. Quality measurement for rhinosinusitis: a review from the Quality Improvement Committee of the American Rhinologic Society. Int Forum Allergy Rhinol 2017; 7:853-860. [DOI: 10.1002/alr.21983] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery; University of Calgary; Calgary AB Canada
| | - Jose Mattos
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston SC
| | - John Schneider
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis MO
| | - Peter R. Manes
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery; Yale School of Medicine; New Haven CT
| | - Janalee K. Stokken
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester MN
| | - Jivianne Lee
- Department of Otolaryngology-Head and Neck Surgery University of California; Los Angeles David Geffen School of Medicine; Los Angeles CA
| | - Thomas S. Higgins
- Department of Otolaryngology-Head and Neck Surgery; University of Louisville; Louisville KY
| | - Rodney J. Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Douglas D. Reh
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore MD
| | - Michael Setzen
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell University; College of Medicine; New York NY
| | - Zachary M. Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston SC
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16
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Vila PM, Rich JT, Desai SC. Defining Quality in Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2017; 157:545-547. [PMID: 28419812 DOI: 10.1177/0194599817703937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Microvascular free flap reconstruction has now become the standard of care in the reconstruction of selected head and neck defects. Although uncommon, flap failure is a catastrophic event that results in significant patient morbidity, extended length of hospitalization, and increased cost. However, there is currently no gold standard for measuring the quality of a reconstructive center. Structure and process outcomes have recently been developed, but outcome measures are still lacking. Areas for future research include preoperative nutrition, preoperative flap planning, intraoperative fluid management, appropriate thromboembolism prophylaxis, consistent perioperative antibiotic regimens, skilled ancillary staff, and clear outcome measures for performance measurement.
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Affiliation(s)
- Peter M Vila
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jason T Rich
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Shaun C Desai
- 2 Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Bethesda, Maryland, USA
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17
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Smith TL, Mace JC, Rudmik L, Schlosser RJ, Hwang PH, Alt JA, Soler ZM. Comparing surgeon outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 2016; 127:14-21. [PMID: 27298069 DOI: 10.1002/lary.26095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/21/2016] [Accepted: 04/20/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers. STUDY DESIGN Prospective, multicenter, observational cohort. METHODS Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling. RESULTS A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ≤ 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535). CONCLUSION Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes. LEVEL OF EVIDENCE 2c. Laryngoscope, 127:14-21, 2017.
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Affiliation(s)
- Timothy L Smith
- Oregon Sinus Center, Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Jess C Mace
- Oregon Sinus Center, Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Peter H Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, California
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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