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Geroin C, Weindelmayer J, Camozzi S, Leone B, Turolo C, Hetoja S, Bencivenga M, Sacco M, De Pasqual CA, Mattioni E, de Manzoni G, Giacopuzzi S. Clinical predictors of postoperative complications in the context of enhanced recovery (ERAS) in patients with esophageal and gastric cancer. Updates Surg 2024; 76:1855-1864. [PMID: 38358642 PMCID: PMC11455705 DOI: 10.1007/s13304-023-01739-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Abstract
The overall frequency of postoperative complications in patients with esophageal and gastric cancer diverges between studies. We evaluated the frequency and assessed the relationship between complications and demographic and clinical features. For this observational study, data were extracted from the ERAS Registry managed by the University of Verona, Italy. Patients were evaluated and compared for postoperative complications according to the consensus-based classification and the Clavien-Dindo scale. The study population was 877 patients: 346 (39.5%) with esophageal and 531 (60.5%) with gastric cancer; 492 (56.2%) reported one or more postoperative complications, 213 (61.6%) of those with esophageal and 279 (52.5%) of those with gastric cancer. When stratified by consensus-based classification, patients with esophageal cancer reported general postoperative complications more frequently (p < 0.001) than those with gastric cancer, but there was no difference in postoperative surgical complications between the two groups. Multiple logistic regression models revealed an association between postoperative complications and the Charlson Comorbidity Index (adjusted odds ratio [OR] 1.22; 95% confidence interval [CI] 1.08-1.36), operation time (adjusted OR, 1.08; 95% CI 1.00-1.15), and days to solid diet intake (adjusted OR, 1.39; 95% CI 1.20-1.59). Complications in patients with esophageal and gastric cancer are frequent, even in those treated according to ERAS principles, and are often associated with comorbidities, longer operative time, and longer time to solid diet intake.
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Affiliation(s)
- Christian Geroin
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy.
| | - Jacopo Weindelmayer
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Serena Camozzi
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Barbara Leone
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Cecilia Turolo
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Selma Hetoja
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Maria Bencivenga
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Michele Sacco
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | | | - Eugenia Mattioni
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Simone Giacopuzzi
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy.
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Schultz KS, Moore MS, Pantel HJ, Mongiu AK, Reddy VB, Schneider EB, Leeds IL. For whom the bell tolls: assessing the incremental costs associated with failure to rescue after elective colorectal surgery. J Gastrointest Surg 2024:S1091-255X(24)00587-0. [PMID: 39181234 DOI: 10.1016/j.gassur.2024.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 08/07/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery. METHODS This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs. RESULTS Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001). CONCLUSION Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.
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Affiliation(s)
- Kurt S Schultz
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Miranda S Moore
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Haddon J Pantel
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Anne K Mongiu
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Vikram B Reddy
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Eric B Schneider
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Ira L Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States.
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Tan CA, Palen L, Su Y, Li Y, Gennarelli RL, Perales MA, Cohen N, Papanicolaou GA, Shah GL, Seo SK. Impact of Primary Letermovir Prophylaxis Versus Preemptive Antiviral Therapy for Cytomegalovirus on Economic and Clinical Outcomes after Hematopoietic Cell Transplantation. Transplant Cell Ther 2024; 30:792.e1-792.e12. [PMID: 38838781 PMCID: PMC11296905 DOI: 10.1016/j.jtct.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/22/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Preemptive therapy (PET) historically has been the primary strategy to reduce early-onset cytomegalovirus (CMV) reactivation after allogeneic hematopoietic cell transplantation (HCT) but is associated with antiviral-associated toxicities and increases in healthcare resource utilization and cost. Despite its high cost, letermovir (LTV) prophylaxis has largely supplanted PET due to its effectiveness and tolerability. Direct comparisons between LTV and PET approaches on economic and clinical outcomes after allogeneic HCT remain limited. Objective: To compare total cost of care (inpatient and outpatient) between LTV prophylaxis and PET through day+180 after allogeneic HCT. Adult allogeneic CMV seropositive (R+) HCT recipients who initiated LTV <30 days after HCT between 01/01/18 and 12/31/18 were matched 1:1 to allogeneic CMV R+ HCT recipients between 01/01/15 and 12/31/17 (PET cohort). Patients were grouped into high-risk (HR) or standard-risk (SR) for CMV to compare the LTV and PET cohorts. Direct costs for each patient's index HCT admission and all subsequent inpatient and outpatient care through day+180 after HCT were determined and converted into 2021 US dollars and then to Medicare proportional dollars (MPD). A secondary analysis using 2019 average wholesale price was conducted to specifically evaluate anti-CMV medication costs. There were a total of 176 patients with 54 HR CMV pairs and 34 SR CMV pairs. No differences in survival between LTV and PET for both HR and SR CMV groups were observed. The rate of clinically significant CMV infection decreased for both HR CMV (11/54, 20.4% versus 38/54, 70.4%, P < .001) and SR CMV (1/34, 2.9% versus 12/34, 35.3%, P < .001) patients who were given LTV prophylaxis with corresponding reductions in val(ganciclovir) and foscarnet (HR CMV only) use. Among HR CMV patients, LTV prophylaxis was associated with reductions in CMV-related readmissions (3/54, 5.6% versus 18/54, 33.3%, P < .001) and outpatient visits within the first 100 days after HCT (20 versus 25, P = .002), and a decreased median total cost of care ($36,018 versus $75,525, P < .001) in MPD was observed. For SR CMV patients on LTV, a significant reduction in the median inpatient cost ($15,668 versus $27,818, P < .001) was found, but this finding was offset by a higher median outpatient cost ($26,145 versus $20,307, P = .030) that was not CMV-driven. LTV prophylaxis is highly effective in reducing clinically significant CMV reactivations for both HR and SR HCT recipients. In this study, LTV prophylaxis was associated with a decreased total cost of care for HR CMV patients through day+180. Specifically, reductions in CMV-related readmissions, exposure to CMV-directed antiviral agents, and outpatient visits in the first 100 days after HCT were observed. SR CMV patients receiving LTV prophylaxis benefited by having a reduced inpatient cost of care due to lowered room and pharmacy costs.
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Affiliation(s)
- Carrie A Tan
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Lauren Palen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York; Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yiqi Su
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuxuan Li
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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Kanno H, Takano Y, Kai W, Takahashi S, Tsukihara S, Kobayashi Y, Hanyu N, Eto K. Association of Cholinesterase With Postoperative Pneumonia After Gastrectomy for Gastric Cancer. J Surg Res 2024; 296:123-129. [PMID: 38277947 DOI: 10.1016/j.jss.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/03/2023] [Accepted: 12/28/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Cholinesterase is a classical marker that reflects nutritional and inflammatory status. The aim of the present study was to evaluate the association between serum cholinesterase levels and postoperative infectious complications in patients undergoing gastrectomy for gastric cancer. MATERIALS AND METHODS This retrospective study comprised 108 patients who underwent gastrectomy for gastric cancer. We comprehensively investigated the association between clinicopathological variables and postoperative infectious complications after gastrectomy. Then patients were divided into the cholinesterase-high and -low groups to analyze their clinicopathological variables. Finally, we analyzed the types of infectious complications that were most associated with preoperative serum cholinesterase levels. RESULTS Twenty-six patients (24%) developed postoperative infectious complications. Multivariate analysis revealed that serum cholinesterase levels (P = 0.026) and N stage (P = 0.009) were independent risk factors for postoperative infectious complications. In particular, the incidence of pneumonia (P = 0.001) was significantly higher in the cholinesterase-low group. Age (P = 0.023), cerebrovascular comorbidities (P = 0.006), serum cholinesterase levels (P = 0.013), and total gastrectomy (P = 0.017) were identified as independent risk factors for postoperative pneumonia. CONCLUSIONS Preoperative serum cholinesterase levels were associated with postoperative pneumonia after gastrectomy for gastric cancer, suggesting the importance of preoperative nutritional assessment in gastric cancer surgery.
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Affiliation(s)
- Hironori Kanno
- Department of Surgery, Tokyo General Hospital, Tokyo, Japan
| | - Yasuhiro Takano
- Department of Surgery, Tokyo General Hospital, Tokyo, Japan.
| | - Wataru Kai
- Department of Surgery, Tokyo General Hospital, Tokyo, Japan
| | | | - Shu Tsukihara
- Department of Surgery, Tokyo General Hospital, Tokyo, Japan
| | | | | | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Becker EC, Salunke R, Saraceni C, Birk J. Biennial Endoscopic Surveillance of Gastrointestinal Metaplasia and Its Subtypes Reduces Gastric Cancer Mortality and Is Cost-Effective in a Markov State Transition Model. South Med J 2023; 116:951-956. [PMID: 38051169 DOI: 10.14423/smj.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Gastric cancer in the United States has a low survival rate mainly because of the late stage of diagnosis. Furthermore, there are no well-established guidelines concerning screening and surveillance even for higher risk patients such as those with nondysplastic noncardia gastrointestinal metaplasia (GIM), and thus they are not routinely performed. This study was designed to provide new evidence-based data that can be used to support the implementation of biennial surveillance guidelines in individuals with nondysplastic noncardia GIM. This practice can help detect early malignant lesions, thereby decreasing morbidity and mortality. We evaluated the cost-effectiveness of surveillance endoscopies for noncardia gastric cancer in populations with two different pathological diagnoses: mixed GIM and incomplete GIM (iGIM). METHODS Markov state transition models were developed using a cohort simulation of 1000 hypothetical patients. Analysis was conducted for both mixed and iGIM. Quality-adjusted life-years and transition probabilities were derived from the published medical literature. Costs associated with endoscopy, cancer care, and surgery were based on Medicare reimbursement. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to determine cost-effectiveness. RESULTS Our study determined that it is significantly cost-effective to perform biennial endoscopy surveillance in patients who have been incidentally found to have noncardia mixed GIM, with a cost savings of $5783.84 per person, and in those with iGIM, with a cost savings of $8093.08 per person. CONCLUSIONS Biennial endoscopy surveillance should be considered in all individuals found to have mixed or incomplete noncardia GIM on endoscopy. Furthermore, screening specifically for iGIM after differentiating between the two groups can lead to further cost savings. As such, we recommend that pathologists routinely differentiate between the two and recommend robust routine surveillance of iGIM.
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Affiliation(s)
| | | | - Corey Saraceni
- Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington
| | - John Birk
- Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington
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Triemstra L, de Jongh C, Tedone F, Brosens LAA, Luyer MDP, Stoot JHMB, Lagarde SM, van Hillegersberg R, Ruurda JP. The Comprehensive Complication Index versus Clavien-Dindo grading after laparoscopic and open D2-gastrectomy in the multicenter randomized LOGICA-trial. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107095. [PMID: 37913608 DOI: 10.1016/j.ejso.2023.107095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index (CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery. METHODS The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation. RESULTS Between 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 [IQR 0-23.5] versus 0 [IQR 0-22.6]; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (rs = 0.646 versus rs = 0.628; p = 0.001, difference clinically irrelevant), and reoperations (rs = 0.590 versus rs = 0.599; p = 0.070), and weak correlations for ICU-stay (rs = 0.446 versus rs = 0.440; p = 0.189). CONCLUSIONS The CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended.
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Affiliation(s)
- Lianne Triemstra
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Cas de Jongh
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Fabrizio Tedone
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | | | - Misha D P Luyer
- Catharina Hospital Eindhoven, Department of Surgery, Eindhoven, the Netherlands
| | - Jan H M B Stoot
- Zuyderland Medical Center, Department of Surgery, Sittard, the Netherlands
| | | | | | - Jelle P Ruurda
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands.
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Li Y, Bai M, Gao Y. Prognostic nomograms for gastric carcinoma after D2 + total gastrectomy to assist decision-making for postoperative treatment: based on Lasso regression. World J Surg Oncol 2023; 21:207. [PMID: 37475024 PMCID: PMC10357773 DOI: 10.1186/s12957-023-03097-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE This study aimed to establish novel nomograms that could be used to predict the prognosis of gastric carcinoma patients who underwent D2 + total gastrectomy on overall survival (OS) and progression-free survival (PFS). METHODS Lasso regression was employed to construct the nomograms. The internal validation process included bootstrapping, which was used to test the accuracy of the predictions. The calibration curve was then used to demonstrate the accuracy and consistency of the predictions. In addition, the Harrell's Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate the discriminative abilities of the new nomograms and to compare its performance with the 8th edition of AJCC-TNM staging. Furthermore, decision curve analysis (DCA) was performed to assess the clinical application of our model. Finally, the prognostic risk stratification of gastric cancer was conducted with X-tile software, and the nomograms were converted into a risk-stratifying prognosis model. RESULTS LASSO regression analysis identified pT stage, the number of positive lymph nodes, vascular invasion, neural invasion, the maximum diameter of tumor, the Clavien-Dindo classification for complication, and Ki67 as independent risk factors for OS and pT stage, the number of positive lymph nodes, neural invasion, and the maximum diameter of tumor for PFS. The C-index of OS nomogram was 0.719 (95% CI: 0.690-0.748), which was superior to the 8th edition of AJCC-TNM staging (0.704, 95%CI: 0.623-0.783). The C-index of PFS nomogram was 0.694 (95% CI: 0.654-0.713), which was also better than that of the 8th edition of AJCC-TNM staging (0.685, 95% CI: 0.635-0.751). The calibration curves, t-ROC curves, and DCA of the two nomogram models showed that the prediction ability of the two nomogram models was outstanding. The statistical difference in the prognosis between the low- and high-risk groups further suggested that our model had an excellent risk stratification performance. CONCLUSION We reported the first risk stratification and nomogram for gastric carcinoma patients with total gastrectomy in Chinese population. Our model could potentially be used to guide treatment selections for the low- and high-risk patients to avoid delayed treatment or unnecessary overtreatment.
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Affiliation(s)
- Yifan Li
- Second Department of General Surgery, Shanxi Province Carcinoma Hospital, Shanxi Hospital Affiliated to Carcinoma Hospital, Chinese Academy of Medical Sciences, Carcinoma Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, People's Republic of China
| | - Min Bai
- Department of Hematopathology, Shanxi Province Carcinoma Hospital, Shanxi Hospital Affiliated to Carcinoma Hospital, Chinese Academy of Medical Sciences, Carcinoma Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, People's Republic of China.
| | - Yuye Gao
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
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Hoeter K, Heinrich S, Wollschläger D, Melchior F, Noack A, Tripke V, Lang H, Thal SC, Bremerich DH. The Optimal Fluid Strategy Matters in Liver Surgery: A Retrospective Single Centre Analysis of 666 Consecutive Liver Resections. J Clin Med 2023; 12:3962. [PMID: 37373656 DOI: 10.3390/jcm12123962] [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: 03/19/2023] [Revised: 05/11/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
As optimal intraoperative fluid management in liver surgery has not been established, we retrospectively analyzed our fluid strategy in a high-volume liver surgery center in 666 liver resections. Intraoperative fluid management was divided into very restrictive (<10 m kg-1 h-1) and normal (≥10 mL kg-1 h-1) groups for study group characterization. The primary endpoint was morbidity as assessed by the Clavien-Dindo (CD) score and the comprehensive complication index (CCI). Logistic regression models identified factors most predictive of postoperative morbidity. No association was found between postoperative morbidity and fluid management in the overall study population (p = 0.89). However, the normal fluid management group had shorter postoperative hospital stays (p = <0.001), shorter ICU stays (p = 0.035), and lower in-hospital mortality (p = 0.02). Elevated lactate levels (p < 0.001), duration (p < 0.001), and extent of surgery (p < 0.001) were the most predictive factors for postoperative morbidity. In the subgroup of major/extreme liver resection, very low total (p = 0.028) and normalized fluid balance (p = 0.025) (NFB) were associated with morbidity. Moreover, fluid management was not associated with morbidity in patients with normal lactate levels (<2.5 mmol/L). In conclusion, fluid management in liver surgery is multifaceted and must be applied judiciously as a therapeutic measure. While a restrictive strategy appears attractive, hypovolemia should be avoided.
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Affiliation(s)
- Katharina Hoeter
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Felix Melchior
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Anna Noack
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Verena Tripke
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Serge C Thal
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Dorothee H Bremerich
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
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Jacobs MA, Tetley JC, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type. J Gastrointest Surg 2023; 27:965-979. [PMID: 36690878 PMCID: PMC10133377 DOI: 10.1007/s11605-022-05576-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/17/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND/PURPOSE Medicare's Hospital Readmission Reduction Program disproportionately penalizes safety-net hospitals (SNH) caring for vulnerable populations. This study assessed the association of insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and cumulative costs in colorectal surgery patients. METHODS Retrospective inpatient cohort study using the National Surgical Quality Improvement Program (2013-2019) with cost data in a SNH. The odds of EDOS and readmissions and cumulative variable (index hospitalization and all 30-day EDOS and readmissions) costs were modeled adjusting for frailty, case status, presence of a stoma, and open versus laparoscopic surgery. RESULTS The cohort had 245 private, 195 Medicare, and 590 Medicaid/uninsured cases, with a mean age 55.0 years (SD = 13.3) and 52.9% of the cases were performed on male patients. Most cases were open surgeries (58.7%). Complication rates were 41.8%, EDOS 12.0%, and readmissions 20.1%. Medicaid/uninsured had increased odds of urgent/emergent surgeries (aOR = 2.15, CI = 1.56-2.98, p < 0.001) and complications (aOR = 1.43, CI = 1.02-2.03, p = 0.042) versus private patients. Medicaid/uninsured versus private patients had higher EDOS (16.6% versus 4.1%) and readmissions (22.9% versus 14.3%) rates and higher odds of EDOS (aOR = 4.81, CI = 2.57-10.06, p < 0.001), and readmissions (aOR = 1.62, CI = 1.07-2.50, p = 0.025), while Medicare patients had similar odds versus private. Cumulative variable cost %change was increased for Medicare and Medicaid/uninsured, but Medicaid/uninsured was similar to private after adjusting for urgent/emergent cases. CONCLUSIONS Increased urgent/emergent cases in Medicaid/uninsured populations drive increased complications odds and higher costs compared to private patients, suggesting lack of access to outpatient care. SNH care for higher cost populations, receive lower reimbursements, and are penalized by value-based programs. Increasing healthcare access for Medicaid/uninsured patients could reduce urgent/emergent surgeries, resulting in fewer complications, EDOS/readmissions, and costs.
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Affiliation(s)
- Michael A Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jasmine C Tetley
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paul Damien
- Department of Information, Risk, and Operations Management, School of Business, University of Texas, Red McCombs, Austin, TX, USA
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA.
- University Health, San Antonio, TX, USA.
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX, USA.
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10
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Cui H, Zhao D, Jian J, Zhang Y, Jian M, Yu B, Hu J, Li Y, Han X, Jiang L, Wang X. Risk factor analysis and construction of prediction models for short-term postoperative complications in patients undergoing gastrointestinal tract surgery. Front Surg 2023; 9:1003525. [PMID: 36684321 PMCID: PMC9845637 DOI: 10.3389/fsurg.2022.1003525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/08/2022] [Indexed: 01/05/2023] Open
Abstract
Purpose To identify risk factors associated with short-term postoperative complications in patients with gastrointestinal cancer and develop and validate prediction models to predict the probability of complications. Methods A total of 335 patients enrolled in the primary cohort of this study were divided into training and validation sets in a chronological order. Using univariate and multivariate logistic regression analyses, the risk factors for postoperative complications were determined, and nomogram prediction models were constructed. The performance of the nomogram was assessed with respect to the receiver operator characteristic and calibration curves. Results Patients with complications had a stronger postoperative stress response and a longer duration of daily fluid intake/output ratio >1 after surgery. Logistic analysis revealed that body mass index (BMI), body temperature on POD4 (T.POD4), neutrophil percentage on POD4 (N.POD4), fasting blood glucose on POD4 (FBG.POD4), and the presence of fluid intake/output ratio <1 within POD4 were risk factors for POD7 complications, and that BMI, T.POD7, N.POD7, FBG.POD4, FBG.POD7, and the duration of daily fluid intake/output ratio >1 were risk factors for POD30 complications. The areas under the curve of Nomogram-A for POD7 complications were 0.867 and 0.833 and those of Nomogram-B for POD30 complications were 0.920 and 0.918 in the primary and validation cohorts, respectively. The calibration curves showed good consistency in both cohorts. Conclusion This study presented two nomogram models to predict short-term postoperative complications in patients with gastrointestinal cancer. The results could help clinicians identify patients at high risk of complications within POD7 or POD30.
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Affiliation(s)
- Hongming Cui
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Dawei Zhao
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Jingren Jian
- Department of Surgical Department, Jinxiang Hongda Hospital Affiliated to Jining Medical University, Jining, China
| | - Yifei Zhang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Mi Jian
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Bin Yu
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Jinchen Hu
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Yanbao Li
- Department of Surgical Department, Yantai Yeda Hospital, Yantai, China
| | - Xiaoli Han
- Department of Surgical Department, Yantai Yeda Hospital, Yantai, China
| | - Lixin Jiang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China,Department of Surgical Department, Yantai Yeda Hospital, Yantai, China,Correspondence: Lixin Jiang Xixun Wang
| | - Xixun Wang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China,Correspondence: Lixin Jiang Xixun Wang
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11
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Wu Z, Yan S, Liu Z, Jing C, Liu F, Yu J, Li Z, Zhang J, Zang L, Hao H, Zheng C, Li Y, Fan L, Huang H, Liang P, Wu B, Zhu J, Niu Z, Zhu L, Song W, You J, Wang Q, Li Z, Ji J. Postoperative abdominal complications of gastric and colorectal cancer surgeries in China: a multicentered prospective registry-based cohort study. Sci Bull (Beijing) 2022; 67:2517-2521. [PMID: 36604028 DOI: 10.1016/j.scib.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/15/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Zhouqiao Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Su Yan
- Department of Gastrointestinal and Oncological Surgery, Affiliated Hospital (& Clinical College) of Qinghai University, Xining 810001, China
| | - Zining Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Fenglin Liu
- Department of General Surgery, Fudan University Zhongshan Hospital, Shanghai 200032, China
| | - Jiang Yu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Zhengrong Li
- Department of General Surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Jian Zhang
- Department of General Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hankun Hao
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chaohui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Yong Li
- Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Lin Fan
- Department of General Surgery, The First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an 710061, China
| | - Hua Huang
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Pin Liang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Dalian Medical University, Dalian 116011, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jiaming Zhu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Jilin University, Changchun 130041, China
| | - Zhaojian Niu
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Linghua Zhu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Wu Song
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510275, China
| | - Jun You
- Gastrointestinal Surgery Department II, Xiamen Oncology Hospital, First Affiliated Hospital, Xiamen University, Xiamen 361003, China
| | - Qi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ziyu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China.
| | - Jiafu Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China.
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12
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Kim J, Jacobs MA, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Manuel LS, Damien P, Shireman PK. Retrospective cohort study comparing surgical inpatient charges, total costs, and variable costs as hospital cost savings measures. Medicine (Baltimore) 2022; 101:e32037. [PMID: 36550805 PMCID: PMC9771214 DOI: 10.1097/md.0000000000032037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We analyzed differences (charges, total, and variable costs) in estimating cost savings of quality improvement projects using reduction of serious/life-threatening complications (Clavien-Dindo Level IV) and insurance type (Private, Medicare, and Medicaid/Uninsured) to evaluate the cost measures. Multiple measures are used to analyze hospital costs and compare cost outcomes across health systems with differing patient compositions. We used National Surgical Quality Improvement Program inpatient (2013-2019) with charge and cost data in a hospital serving diverse socioeconomic status patients. Simulation was used to estimate variable costs and total costs at 3 proportions of fixed costs (FC). Cases (Private 1517; Medicare 1224; Medicaid/Uninsured 3648) with patient mean age 52.3 years (Standard Deviation = 14.7) and 47.3% male. Medicare (adjusted odds ratio = 1.55, 95% confidence interval = 1.16-2.09, P = .003) and Medicaid/Uninsured (adjusted odds ratio = 1.41, 95% confidence interval = 1.10-1.82, P = .008) had higher odds of complications versus Private. Medicaid/Uninsured had higher relative charges versus Private, while Medicaid/Uninsured and Medicare had higher relative variable and total costs versus Private. Targeting a 15% reduction in serious complications for robust patients undergoing moderate-stress procedures estimated variable cost savings of $286,392. Total cost saving estimates progressively increased with increasing proportions of FC; $443,943 (35% FC), $577,495 (50% FC), and $1184,403 (75% FC). In conclusion, charges did not identify increased costs for Medicare versus Private patients. Complications were associated with > 200% change in costs. Surgical hospitalizations for Medicare and Medicaid/Uninsured patients cost more than Private patients. Variable costs should be used to avoid overestimating potential cost savings of quality improvement interventions, as total costs include fixed costs that are difficult to change in the short term.
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Affiliation(s)
- Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX, USA
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Departments of Primary Care and Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX, USA
- * Correspondence: Paula K. Shireman, Office of the Dean, School of Medicine, Texas A&M Health, 8447 Riverside Parkway, Bryan TX 77807, USA (e-mail: )
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13
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Aggarwal VA, Sambandam SN, Wukich DK. The impact of obesity on total knee arthroplasty outcomes: A retrospective matched cohort study. J Clin Orthop Trauma 2022; 33:101987. [PMID: 36089991 PMCID: PMC9449637 DOI: 10.1016/j.jcot.2022.101987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 10/15/2022] Open
Abstract
Background Total Knee Arthroplasty (TKA) is a common orthopaedic surgery to treat advanced knee arthritis. Post-operative complications can be affected by obesity, defined as a body mass index of 30 kg/m2 or higher. We examine the rates of specific complications, revision rates, and costs of care following TKA and compare them between multifactor matched obese and non-obese patients. We hypothesize these outcomes will be worse in obese patients than in non-obese patients. Methods This retrospective study of the PearlDiver database queries for patients who underwent TKA under Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9) codes between January 2011 and January 2020. Patients were matched based on age, gender, and comorbidity indices, and various complications, revision rates, and costs were compared between the matched obese and non-obese patient groups. Results Obesity was associated with higher rates of surgical complications, such as wound complications, surgical site infections, need for revision, and higher total cost of care one year after TKA, and medical complications such as, acute kidney injury, deep vein thrombosis, urinary tract infection, and narcotics use, but significantly lower rates of anemia, arrhythmia, cardiac arrest, pneumonia, and transfusion. Obese patients also experienced significantly lower drug costs of care. Conclusion Outcomes were not definitively worse in obese patients when compared to matched non-obese patients. Nevertheless, understanding the complications that can arise following TKA will assist in educating patients about potential risks from surgery and guide surgeons in caring for their patients as obesity is predicted to continue increasing in prevalence. As such, future studies should examine underlying mechanisms that cause these complications to develop potential therapies.
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Affiliation(s)
| | - Senthil N Sambandam
- University of Texas Southwestern, Staff Orthopedic Surgeon, Dallas VAMC, Dallas, TX, USA
| | - Dane K Wukich
- Department of Orthopaedics, University of Texas Southwestern, Dallas, TX, USA
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14
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Zheng X, Ding S, Wu M, Sun C, Wu Y, Wang S, Du Y, Yang L, Xue L, Wang B, Wang C, Cui W, Xie Y. Dynamic monitoring revealed a slightly prolonged waiting time for total gastrectomy during the COVID-19 pandemic without increasing the short-term complications. Front Oncol 2022; 12:944602. [PMID: 36119493 PMCID: PMC9471957 DOI: 10.3389/fonc.2022.944602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/17/2022] [Indexed: 01/08/2023] Open
Abstract
We aimed to determine the pattern of delay and its effect on the short-term outcomes of total gastrectomy before and during the coronavirus disease 2019 (COVID-19) pandemic. Overlaid line graphs were used to visualize the dynamic changes in the severity of the pandemic, number of gastric cancer patients, and waiting time for a total gastrectomy. We observed a slightly longer waiting time during the pandemic (median: 28.00 days, interquartile range: 22.00–34.75) than before the pandemic (median: 25.00 days, interquartile range: 18.00–34.00; p = 0.0071). Moreover, we study the effect of delayed surgery (waiting time > 30 days) on short-term outcomes using postoperative complications, extreme value of laboratory results, and postoperative stay. In patients who had longer waiting times, we did not observe worse short-term complication rates (grade II–IV: 15% vs. 19%, p = 0.27; grade III–IV: 7.3% vs. 9.2%, p = 0.51, the short waiting group vs. the prolonged waiting group) or a higher risk of a longer POD (univariable: OR 1.09, 95% CI 0.80–1.49, p = 0.59; multivariable: OR 1.10, 95% CI 0.78–1.55, p = 0.59). Patients in the short waiting group, rather than in the delayed surgery group, had an increased risk of bleeding in analyses of laboratory results (plasma prothrombin activity, hemoglobin, and hematocrit). A slightly prolonged preoperative waiting time during COVID-19 pandemic might not influence the short-term outcomes of patients who underwent total gastrectomy.
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Affiliation(s)
- Xiaohao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shikang Ding
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Wu
- Department of Gastrointestinal Surgery, Yun Cheng Center Hospital, Yuncheng, China
| | - Chunyang Sun
- Department of General Surgery, The Central Hospital of Jia Mu Si City, Jiamusi, China
| | - Yunzi Wu
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shenghui Wang
- Department of General Surgery, Civil Aviation General Hospital, Beijing, China
| | - Yongxing Du
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Yang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liyan Xue
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingzhi Wang
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chengfeng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Chengfeng Wang, ; Wei Cui, ; Yibin Xie,
| | - Wei Cui
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Chengfeng Wang, ; Wei Cui, ; Yibin Xie,
| | - Yibin Xie
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, China
- *Correspondence: Chengfeng Wang, ; Wei Cui, ; Yibin Xie,
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15
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Effects of EN combined with PN enriched with n-3 polyunsaturated fatty acids on immune related indicators and early rehabilitation of patients with gastric cancer: A randomized controlled trial. Clin Nutr 2022; 41:1163-1170. [DOI: 10.1016/j.clnu.2022.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/17/2022] [Accepted: 03/11/2022] [Indexed: 02/08/2023]
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Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis. Dis Colon Rectum 2021; 64:1426-1434. [PMID: 34623350 PMCID: PMC8502230 DOI: 10.1097/dcr.0000000000001966] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications. OBJECTIVE The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a comprehensive cancer center. PATIENTS Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study. MAIN OUTCOME MEASURES Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d). RESULTS Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories. LIMITATIONS The study was limited by its retrospective design and generalizability. CONCLUSIONS The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521. EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.
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17
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Ludbrook GL. The Hidden Pandemic: the Cost of Postoperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:1-9. [PMID: 34744518 PMCID: PMC8558000 DOI: 10.1007/s40140-021-00493-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/17/2022]
Abstract
Purpose of Review Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing. Recent Findings Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change. Summary Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.
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Affiliation(s)
- Guy L. Ludbrook
- The University of Adelaide, and Royal Adelaide Hospital, C/O Royal Adelaide Hospital, 3G395, 1 Port Road, Adelaide, South Australia 5000 Australia
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18
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van Kooten RT, Bahadoer RR, Peeters KCMJ, Hoeksema JHL, Steyerberg EW, Hartgrink HH, van de Velde CJH, Wouters MWJM, Tollenaar RAEM. Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review. Eur J Surg Oncol 2021; 47:3049-3058. [PMID: 34340874 DOI: 10.1016/j.ejso.2021.07.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/16/2021] [Accepted: 07/24/2021] [Indexed: 12/20/2022] Open
Abstract
Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.
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Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jetty H L Hoeksema
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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19
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Stewart C, Wong P, Warner S, Raoof M, Singh G, Fong Y, Melstrom L. Robotic minor hepatectomy: optimizing outcomes and cost of care. HPB (Oxford) 2021; 23:700-706. [PMID: 32988754 DOI: 10.1016/j.hpb.2020.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/08/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. METHODS We queried the medical record and cost data for patients who underwent open or robotic minor (1-2 segment) liver resection from 1/2016-8/2019. Financial data were normalized to Medicare reimbursements. RESULTS There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p < 0.001) were significantly lower for patients who underwent robotic resection. These factors contributed to minor robotic liver resections costing $534 less than open resections ($3597 ± 1823 vs $4131 ± 1532, p = 0.03). CONCLUSION Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.
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Affiliation(s)
- Camille Stewart
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Paul Wong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Susanne Warner
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
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20
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Brown O, Mou T, Kenton K, Sheyn D, Bretschneider CE. Racial disparities in complications and costs after surgery for pelvic organ prolapse. Int Urogynecol J 2021; 33:385-395. [PMID: 33755740 DOI: 10.1007/s00192-021-04726-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP). METHODS In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal-Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively. RESULTS A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p < 0.01). The median total cost associated with surgeries for POP was $8,267 (IQR $6,008-$11,734). After multivariate analyses controlled for potential confounders, postoperative complications remained independently associated with Black race (aOR 1.21) whereas Hispanic and other races were associated with decreased odds of complications (aOR 0.62, and aOR 0.77) relative to white race. After controlling for confounders, Hispanic women had lower associated hospital costs. CONCLUSIONS Black women undergoing inpatient surgery for POP had a 21% increase in the odds of complications, but no difference in costs compared with white women, whereas Hispanic women had the lowest odds of complications and lowest costs.
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Affiliation(s)
- Oluwateniola Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA.
| | - Tsung Mou
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
| | - Kimberly Kenton
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Metro Health Medical Center, Cleveland, OH, USA
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
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Morimoto M, Taniguchi K, Yamamoto O, Naka T, Sugitani A, Fujiwara Y. Evaluation of Blood Supply with Indocyanine Green Fluorescence in Resection for Concurrent Gastric and Pancreatic Cancer: A Case Report. Yonago Acta Med 2021; 64:133-136. [PMID: 33642914 DOI: 10.33160/yam.2021.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/03/2021] [Indexed: 02/05/2023]
Abstract
We present a rare case of concurrent resection of pancreatic and gastric cancer in which indocyanine green (ICG) fluorescence was used to evaluate the remnant stomach. An 80-year-old man was referred with a tumor in the distal pancreas. Computed tomography showed a 25-mm mass in the pancreatic tail; endoscopic ultrasound-guided fine-needle aspiration revealed adenocarcinoma. Upper gastrointestinal endoscopy and subsequent upper gastrointestinal series revealed advanced gastric cancer in the mid-stomach. Concurrent resection of the pancreatic and gastric tumors was performed. After distal pancreatectomy and distal gastrectomy, ICG evaluation of the stomach showed fluorescence extending only 3 cm distal from the cardia. To avoid ischemic change at the remnant stomach, total gastrectomy was performed. Since remnant gastric necrosis and anastomotic leak following ischemia can lead to fatal outcomes, the use of ICG to evaluate blood supply at anastomotic sites can help determine the extent of safe resection in such cases.
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Affiliation(s)
- Masaki Morimoto
- National Hospital Organization Yonago Medical Center, Yonago 683-0006, Japan and.,Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Kenjiro Taniguchi
- National Hospital Organization Yonago Medical Center, Yonago 683-0006, Japan and
| | - Osamu Yamamoto
- National Hospital Organization Yonago Medical Center, Yonago 683-0006, Japan and
| | - Takuji Naka
- National Hospital Organization Yonago Medical Center, Yonago 683-0006, Japan and
| | - Atsushi Sugitani
- National Hospital Organization Yonago Medical Center, Yonago 683-0006, Japan and
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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22
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The Cost of Postoperative Complications and Economic Validation of the Comprehensive Complication Index: Prospective Study. Ann Surg 2021; 273:112-120. [PMID: 30985367 DOI: 10.1097/sla.0000000000003308] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs. BACKGROUND The CCI summarizes all the postoperative complications graded by the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date. METHODS Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded. RESULTS In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444-0.810 vs 0.445-0.820; P < 0.001), homogeneous surgeries (rs = 0.364-0.802 vs 0.364-0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001). CONCLUSIONS In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.
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He Q, Zhu J, Wang A, Ji K, Ji X, Zhang J, Wu X, Li X, Bu Z, Ji J. A decision analysis comparing three strategies for peritoneal lavage cytology testing in staging of gastric cancer in China. Cancer Med 2020; 9:8940-8949. [PMID: 33047873 PMCID: PMC7724308 DOI: 10.1002/cam4.3518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Positive peritoneal cytology (PCY) indicates metastasis (M1) in gastric cancer (GC) patients; both the American and Chinese guidelines recommend laparoscopic peritoneal lavage (LPL) for cytology. However, relatively high costs impair the widespread use of LPL in some resource-limited regions in China, and the cost-effectiveness of PCY testing remains unclear. Therefore, we performed a decision analysis to evaluate the cost-effectiveness of PCY testing by comparing the guideline-recommended intraoperative LPL, a newly proposed preoperative percutaneous peritoneal lavage (PPL), and a third strategy of exploratory laparotomy with no cytology testing (ELNC) among GC patients. METHODS We developed a decision-analytic Markov model of the aforementioned three strategies for a hypothetical cohort of GC patients with curative intent after initial imaging, from the perspective of Chinese society. We estimated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) as primary outcomes; we also conducted one-way and probabilistic sensitivity analyses to investigate the model's robustness. RESULTS We found that ELNC was dominated (i.e., more expensive and less effective) by PPL and LPL. LPL was the most cost-effective method with an ICER of US$17,200/QALY compared to PPL, which was below the Chinese willingness-to-pay (WTP) threshold of US$29,313 per QALY gained. In sensitivity analyses, PPL was more likely to be cost-effective with a lower WTP threshold. CONCLUSIONS Cytology testing through either LPL or PPL was less expensive and more effective than ELNC among GC patients. Moreover, LPL was the most cost-effective modality at the current WTP threshold, while PPL could potentially be cost-effective in lower-income areas.
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Affiliation(s)
- Qifei He
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Jinyi Zhu
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Anqiang Wang
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Ke Ji
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Xin Ji
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Ji Zhang
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Xiaojiang Wu
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Xia Li
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Zhaode Bu
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
| | - Jiafu Ji
- Department of Gastrointestinal SurgeryKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education)Peking University Cancer Hospital & InstituteBeijingChina
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Ferguson BD, Jones GD, Skovgard M, Molena D, Huang J, Bott MJ, Sihag S, Park BJ, Adusumilli PS, Downey RJ, Isbell JM, Rusch VW, Bains MS, Jones DR, Rocco G. Is Routine Chest Radiography Necessary After Endobronchial Ultrasound-guided Fine Needle Aspiration? Ann Thorac Surg 2020; 112:467-472. [PMID: 33096072 DOI: 10.1016/j.athoracsur.2020.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/28/2020] [Accepted: 08/24/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chest radiography is routinely performed after endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) to detect clinically occult pneumothorax. Because the established rate of postprocedure pneumothorax is low, this study sought to determine whether routine chest radiography can be safely eliminated and to ascertain the potential cost reduction with its omission. METHODS Patients who underwent EBUS-FNA between January 1, 2017 and December 31, 2018 at Memorial Sloan Kettering Cancer Center (New York, NY) were retrospectively identified. Patient-related factors were summarized using descriptive statistics. Outcomes were compared using the χ2, Fisher exact, and analysis of variance tests. Univariate regression analysis was used to identify factors predictive of postprocedure pneumothorax. RESULTS A total of 757 patients were included in the study: 72.4% (548 of 757) underwent routine chest radiography in the postanesthesia care unit. Clinically relevant or radiographically evident pneumothorax developed in 1.5% of patients (11 of 757). Of the patients who underwent chest radiography, 0.5% (3 of 548) required unplanned admission for postprocedure pneumothorax, and 0.2% (1 of 548) required tube thoracostomy. Of the 209 patients who did not undergo chest radiography, none experienced a clinically evident pneumothorax. In total, only 1 patient (0.1%) had symptomatic pneumothorax. The pneumothorax event rate was so low that no association with demographic or clinical factors and no predictive factors could be identified. The number of patients needed to be screened by chest radiography to identify 1 patient requiring deviation from routine management is 183. The potential total cost reduction if routine chest radiography had been eliminated was $33,950. CONCLUSIONS The extremely low rate of postprocedure pneumothorax precluded informative statistical analysis. Routine chest radiography after EBUS-FNA may not be necessary, and its omission may confer a cost savings.
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Affiliation(s)
- Benjamin D Ferguson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gregory D Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew Skovgard
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gaetano Rocco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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25
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Bausys A, Luksta M, Kuliavas J, Anglickiene G, Maneikiene V, Gedvilaite L, Celutkiene J, Jamontaite I, Cirtautas A, Lenickiene S, Vaitkeviciute D, Gaveliene E, Klimaviciute G, Bausys R, Strupas K. Personalized trimodal prehabilitation for gastrectomy. Medicine (Baltimore) 2020; 99:e20687. [PMID: 32629639 PMCID: PMC7337474 DOI: 10.1097/md.0000000000020687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Surgery is the only potentially curative treatment for gastric cancer, however, it bears a high postoperative morbidity and mortality rate. A recent randomized control trial proposed prehabilitation to reduce the postoperative morbidity in patients undergoing major abdominal surgery. Currently, there is a lack of evidence of using prehabilitation for patients undergoing gastrectomy for gastric cancer. The aim of our study is to demonstrate that home-based prehabilitation can reduce postoperative morbidity after gastrectomy for gastric cancer. METHODS PREFOG is a multi-center, open-label randomized control trial comparing 90-days postoperative morbidity rate after gastrectomy for gastric cancer between patients with or without prehabilitation. One-hundred twenty-eight patients will be randomized into an intervention or control group. The intervention arm will receive trimodal home-based prehabilitation including nutritional, psychological and exercise interventions. Secondary outcomes of the study will include physical and nutritional status, anxiety and depression level, quality of life, postoperative mortality rates and full completion of the oncological treatment as determined by the multidisciplinary tumor board. DISCUSSION PREFOG study will show if home-based trimodal prehabilitation is effective to reduce postoperative morbidity after gastrectomy for gastric cancer. Moreover, this study will allow us to determine whether prehabilitation can improve physical fitness and activity levels, nutritional status and quality of life as well as reducing anxiety and depression levels after gastrectomy for gastric cancer. TRIAL REGISTRATION ClinicalTrials.gov NCT04223401 (First posted: 10 January 2020).
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Affiliation(s)
- Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Justas Kuliavas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | | | - Vyte Maneikiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine of the Faculty of Medicine
| | - Lina Gedvilaite
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine of the Faculty of Medicine
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine of the Faculty of Medicine
| | - Ieva Jamontaite
- Department of Rehabilitation, Physical and Sports Medicine, Institute of Health Sciences, Faculty of Medicine, Vilnius University
| | - Alma Cirtautas
- Department of Rehabilitation, Physical and Sports Medicine, Institute of Health Sciences, Faculty of Medicine, Vilnius University
| | - Svetlana Lenickiene
- Department of Rehabilitation, Physical and Sports Medicine, Institute of Health Sciences, Faculty of Medicine, Vilnius University
| | - Dalia Vaitkeviciute
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Edita Gaveliene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | | | - Rimantas Bausys
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
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Hu Y, Briggs A, Gennarelli RL, Bartlett EK, Ariyan CE, Coit DG, Brady MS. Sentinel Lymph Node Biopsy for T1b Melanoma: Balancing Prognostic Value and Cost. Ann Surg Oncol 2020; 27:5248-5256. [PMID: 32514805 DOI: 10.1245/s10434-020-08558-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The purpose of this study is to report the additional prognostic information and cost associated with sentinel lymph node biopsy (SLNB) for patients with T1b melanoma. PATIENTS AND METHODS An institutional database was queried for patients with T1b melanoma (0.8-1.0 mm or < 0.8 mm with ulceration) with at least 5 years of follow-up. Results of SLNB, completion lymphadenectomy (CLND), recurrence, and melanoma-specific survival (MSS) were assessed. Institutional costs of melanoma care were converted to Medicare proportional dollars. A Markov model was created to estimate long-term costs. RESULTS Among the total 392 patients, 238 underwent SLNB. Median follow-up was 10.5 years. SLNB was positive in 19 patients (8.0%). Patients who underwent SLNB had higher 10-year nodal recurrence-free survival (98.6% vs. 91.2%, p < 0.001) but not MSS (94.4% vs. 93.2%, p = 0.55). Ulceration (HR 4.7, p = 0.022) and positive sentinel node (HR 11.5, p < 0.001) were associated with worse MSS. Estimates for 5-year costs reflect a fourfold increase in total costs of care associated with SLNB. However, a treatment plan that forgoes adjuvant therapy for resected stage IIIA melanoma but offers systemic therapy for a node-basin recurrence would nullify the additional cost of SLNB. CONCLUSIONS SLNB is prognostic for T1b melanoma. Its impact on the overall cost of melanoma care is intimately tied to systemic therapy in the adjuvant and recurrent settings.
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Affiliation(s)
- Yinin Hu
- Division of Surgical Oncology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Briggs
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renee L Gennarelli
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edmund K Bartlett
- Division of Surgical Oncology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charlotte E Ariyan
- Division of Surgical Oncology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel G Coit
- Division of Surgical Oncology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary S Brady
- Division of Surgical Oncology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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27
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Sivakumar J, Alnimri F, Johnson MA, Ward S, Chong L, Hii MW. Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications. ANZ J Surg 2020; 91:E1-E6. [PMID: 32483869 DOI: 10.1111/ans.16014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications. METHODS A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared. RESULTS A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%). CONCLUSION The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.
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Affiliation(s)
- Jonathan Sivakumar
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Feras Alnimri
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mary A Johnson
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Salena Ward
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Lynn Chong
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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28
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Intracorporeal Anastomoses in Minimally Invasive Right Colectomies Are Associated With Fewer Incisional Hernias and Shorter Length of Stay. Dis Colon Rectum 2020; 63:685-692. [PMID: 32168093 PMCID: PMC7148181 DOI: 10.1097/dcr.0000000000001612] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Intracorporeal anastomosis is associated with several short-term benefits. However, it is a technically challenging procedure with potential risk OBJECTIVE:: The purpose of this study was to investigate differences in short-term complications and long-term incisional hernia rates after robotic right colectomy with intracorporeal versus extracorporeal anastomoses and standardized extraction sites. DESIGN This was a historical cohort study. SETTINGS The study was conducted at a single institution. PATIENTS All of the patients undergoing robotic right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site or extracorporeal anastomosis with a vertical midline extraction site from 2013 to 2017 were eligible. Exclusion criteria were conversion to laparotomy for tumor-related reasons or lack of follow-up. INTERVENTION Intracorporeal or extracorporeal anastomosis was performed, based on availability of the robotic stapler and appropriate bedside assistance. MAIN OUTCOME MEASURES The primary outcome was incisional hernia, diagnosed either clinically or on postoperative imaging, and analyzed using time-to-event analysis. A Cox proportional hazards model was used for multivariable analysis. Secondary outcomes were analyzed using parametric and nonparametric tests. Statistical significance was set at p < 0.05. RESULTS Of 164 patients who met all inclusion criteria, 67 had intracorporeal and 97 had extracorporeal anastomoses. Median follow-up time was similar in both groups (14 vs 15 mo; p = 0.73). The 1-year estimated incisional hernia rate was 12% for extracorporeal and 2% for intracorporeal anastomoses (p = 0.007); this difference was confirmed by multivariable modeling. The severity of postoperative complications was similar between the groups, but there was an increase in incisional infections and a shorter length of stay (1 day) for intracorporeal cases. LIMITATIONS The study was limited by its retrospective, single-surgeon nature. CONCLUSIONS Right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site may reduce the rate of incisional hernias compared with extracorporeal anastomosis with a vertical midline extraction site. The intracorporeal approach was also associated with a decreased length of stay but an increase in incisional surgical site infections. These findings have implications for healthcare use and patient-centered outcomes. See Video Abstract at http://links.lww.com/DCR/B147. ANASTOMOSIS INTRACORPÓREAS EN COLECTOMÍAS DERECHAS MÍNIMAMENTE INVASIVAS SE ASOCIAN CON MENOS HERNIAS INCISIONALES Y UNA ESTADÍA HOSPITALARIA MÁS BREVE: nastomosis intracorpórea se asocia con varios beneficios a corto plazo. Sin embargo, es un procedimiento técnicamente desafiante con riesgos potenciales.nvestigar las diferencias en las complicaciones a corto plazo y las tasas de hernia incisional a largo plazo después de la colectomía robótica derecha con anastomosis intracorpórea versus extracorpórea y sitios de extracción estandarizados.Estudio de cohorte histórico.cirujano individual, institución única.Todos los pacientes sometidos a colectomía robótica derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel o anastomosis extracorpórea con un sitio de extracción vertical de la línea media de 2013-2017 fueron elegibles. Los criterios de exclusión fueron la conversión a laparotomía por razones relacionadas con el tumor o la falta de seguimiento.nastomosis intracorpórea o extracorpórea, según la disponibilidad de grapadora robótica y la asistencia adecuada quirúrgica.El resultado primario fue la hernia incisional, diagnosticada clínicamente o en imágenes postoperatorias, y analizada mediante análisis de tiempo hasta el evento. Se usó un modelo de riesgos proporcionales de Cox para el análisis multivariable. Los resultados secundarios se analizaron mediante pruebas paramétricas y no paramétricas. La significación estadística se estableció en p < 0,05.De 164 pacientes que cumplieron con todos los criterios de inclusión, 67 tenían anastomosis intracorpóreas y 97 tenían anastomosis extracorpóreas. La mediana del tiempo de seguimiento fue similar en ambos grupos (14 versus 15 meses, p = 0,73). La tasa de hernia incisional estimada para un año fue del 12% para las anastomosis extracorpóreas y del 2% para las anastomosis intracorpóreas (p = 0,007); esta diferencia fue confirmada por el modelado multivariable. La gravedad de las complicaciones postoperatorias fue similar entre los grupos, pero hubo un aumento de las infecciones incisionales y una estancia más corta (un día) para los casos intracorpóreos.Retrospectiva, cirujano único.a colectomía derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel puede reducir la tasa de hernias incisionales en comparación con la anastomosis extracorpórea con un sitio de extracción vertical en la línea media. El enfoque intracorpóreo también se asoció con una disminución de la duración de la estadía, pero con un aumento de las infecciones del sitio quirúrgico incisional. Estos hallazgos tienen implicaciones para la utilización de recursos médicos y beneficios para pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B147. (Traducción-Dr. Adrian Ortega).
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Impact of Postoperative Complication and Completion of Multimodality Therapy on Survival in Patients Undergoing Gastrectomy for Advanced Gastric Cancer. J Am Coll Surg 2020; 230:912-924. [PMID: 32035978 DOI: 10.1016/j.jamcollsurg.2019.12.038] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/01/2019] [Accepted: 12/18/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Postoperative complication (POC) adversely impacts long-term survival in patients with gastric cancer, perhaps due in part to lower rates for receipt of multimodality therapy (MMT). We sought to determine the impact of POC on MMT completion rates and overall survival (OS) in patients with locally advanced gastric cancer. STUDY DESIGN We analyzed 206 patients with locally advanced gastric cancer undergoing curative-intent resection from 2001 to 2015. POCs were graded using Clavien-Dindo classification and survival outcomes were compared between groups. RESULTS One hundred and twenty patients underwent operation followed by chemoradiation therapy, 58 received perioperative chemotherapy, and 28 received total neoadjuvant therapy (TNT). Minor (Clavien-Dindo grade I to II) and major (Clavien-Dindo grade III to IV) POC occurred in 72 (35.0%) and 39 (18.9%) patients, respectively. At median follow-up of 37 months, the 3-year OS of patients experiencing a major, minor, or no POC were 33.3%, 56.9%, and 62.1% (p = 0.023), respectively. In contrast, there was no difference in 3-year OS rates in patients experiencing POC if they completed all intended MMT. Non-TNT patients who experienced a major POC were less likely to complete MMT (hazard ratio 0.36, p = 0.017), and a major POC in these patients had a significant impact on OS (hazard ratio 2.76, p = 0.011), and it did not in patients who completed MMT (hazard ratio 1.58, p = 0.336). CONCLUSIONS Major POC adversely affects long-term survival after gastrectomy for gastric cancer, at least in part via lower completion rates of MMT. Treatment strategy designed to ensure the completion of MMT, such as TNT, might be preferable, particularly for patients at high risk for POCs.
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Stewart CL, Wong P, Selby L, Warner SG, Raoof M, Singh G, Fong Y, Melstrom LG. Minimally invasive distal pancreatectomy and the cost of conversion. J Surg Oncol 2020; 121:670-675. [PMID: 31967336 DOI: 10.1002/jso.25852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/26/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.
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Affiliation(s)
| | - Paul Wong
- Department of Surgery, City of Hope, Duarte, California
| | - Luke Selby
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, California
| | | | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, California
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Dan Z, YiNan D, ZengXi Y, XiChen W, JieBin P, LanNing Y. Thirty-Day Readmission After Radical Gastrectomy for Gastric Cancer: A Meta-analysis. J Surg Res 2019; 243:180-188. [DOI: 10.1016/j.jss.2019.04.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 01/03/2023]
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Barchi LC, Ramos MFKP, Pereira MA, Dias AR, Ribeiro-Júnior U, Zilberstein B, Cecconello I. Esophagojejunal anastomotic fistula: a major issue after radical total gastrectomy. Updates Surg 2019; 71:429-438. [PMID: 31161587 DOI: 10.1007/s13304-019-00659-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Abstract
Gastric cancer surgery has evolved considerably over the past years, with substantial improvement on outcomes. Meanwhile, esophagojejunal anastomotic fistula (EJF) continues to impair postoperative results. This study aimed to assess EJF regarding its incidence, risk factors, management and the impact on overall survival. We retrospectively analyzed 258 consecutive patients who underwent total or completion gastrectomy for GC from 2009 and 2017. Clinicopathological characteristics analysis was performed comparing patients who developed EJF with patients with other clinical or surgical complications, as well as patients without any postoperative complications. Fifteen (5.8%) patients had EJF and 81 (31.4%) had other complications (including other surgical fistulas). The median time of EJF diagnosis was on the eighth postoperative day (range 3-76). Completion gastrectomy (p = 0.048) and longer hospital stay (p < 0.001) were associated with the occurrence of EJF. The surgical mortality of patients with EJF was higher than in non-EJF patients (26.7% vs. 4.5%; p < 0.001). Nine patients were treated conservatively and six required surgery. The mortality rate of EJF was 11.1% and 50% in patients who underwent conservative and surgical treatment, respectively. Patients with other complications and patients with EJF had worse survival compared to patients without any complication (p = 0.004 and p = 0.013, respectively). Completion gastrectomy is the main risk factor for EJF occurrence. Still, EJF is associated with high postoperative mortality, longer hospital stay and has a negative impact on long-term survival.
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Affiliation(s)
- Leandro Cardoso Barchi
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil.
| | | | - Marina Alessandra Pereira
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - André Roncon Dias
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ulysses Ribeiro-Júnior
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Bruno Zilberstein
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ivan Cecconello
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
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Asaoka R, Kawamura T, Makuuchi R, Irino T, Tanizawa Y, Bando E, Terashima M. Risk factors for 30-day hospital readmission after radical gastrectomy: a single-center retrospective study. Gastric Cancer 2019; 22:413-420. [PMID: 30006830 DOI: 10.1007/s10120-018-0856-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital readmission is gathering greater attention as a measure of health care quality. The introduction of fast-track surgery has led to shorter lengths of hospitalization without increasing the risk of postoperative complications and readmission. The collection of comprehensive readmission data is essential for the further improvement of patient care. The aim of the present study is to evaluate the risk factors for readmission within 30 days of discharge after gastrectomy. METHODS A total of 1929 patients who underwent radical gastrectomy at Shizuoka Cancer Center were included in this study. A risk analysis with a stepwise logistic regression model was conducted to identify the risk factors for 30-day hospital readmission. RESULTS The 30-day readmission rate was 2.70%. Common causes of readmission were an intolerance of oral intake and the presence of an intra-abdominal abscess. The C reactive protein (CRP) level on postoperative day (POD) 3 was significantly higher in the readmitted group; however, the other surgical outcomes, including the incidence of postoperative complications, did not differ to a statistically significant extent. The stepwise logistic regression analysis revealed that CRP on POD3 ≥ 12 mg/dl [odds ratio (OR) 2.08, 95% confidence interval (CI) 1.09-3.95, p = 0.025], laparoscopic surgery (OR 2.25, 95% CI 1.17-4.31, p = 0.015), and TG (OR 2.23, 95% CI 1.17-4.78, p = 0.023) were found to be independent risk factors for readmission. CONCLUSIONS CRP on POD3 ≥ 12 mg/dl, laparoscopic surgery, and TG were identified as independent risk factors for readmission.
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Affiliation(s)
- Raito Asaoka
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Taiichi Kawamura
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Rie Makuuchi
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Tomoyuki Irino
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yutaka Tanizawa
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Etsuro Bando
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masanori Terashima
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
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Zogg CK, Ottesen TD, Kebaish KJ, Galivanche A, Murthy S, Changoor NR, Zogg DL, Pawlik TM, Haider AH. The Cost of Complications Following Major Resection of Malignant Neoplasia. J Gastrointest Surg 2018; 22:1976-1986. [PMID: 29946953 PMCID: PMC6224301 DOI: 10.1007/s11605-018-3850-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rising healthcare costs have led to increased focus on the need to achieve a higher "value of care." As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally representative data. METHODS National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥ 18 years) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One fourth (26.1%; 95% CI, 25.7-26.4%) experienced ≥ 1 pre-discharge complication (range, 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, 67 Cedar Street, Room 316 ESH, New Haven, CT, 06520, USA.
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Taylor D Ottesen
- Yale School of Medicine, 67 Cedar Street, Room 316 ESH, New Haven, CT, 06520, USA
| | - Kareem J Kebaish
- Yale School of Medicine, 67 Cedar Street, Room 316 ESH, New Haven, CT, 06520, USA
| | - Anoop Galivanche
- Yale School of Medicine, 67 Cedar Street, Room 316 ESH, New Haven, CT, 06520, USA
| | - Shilpa Murthy
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Navin R Changoor
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Donald L Zogg
- Minnesota Gastroenterology, P.A., Saint Paul, MN, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Jiang R, Liu Y, Ward KC, Force SD, Pickens A, Sancheti MS, Javidfar J, Fernandez FG, Khullar OV. Excess Cost and Predictive Factors of Esophagectomy Complications in the SEER-Medicare Database. Ann Thorac Surg 2018; 106:1484-1491. [PMID: 29944881 DOI: 10.1016/j.athoracsur.2018.05.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 05/13/2018] [Accepted: 05/21/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. METHODS The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost. RESULTS A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications. CONCLUSIONS Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.
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Affiliation(s)
- Renjian Jiang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin C Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Seth D Force
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Pickens
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Manu S Sancheti
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey Javidfar
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Felix G Fernandez
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Onkar V Khullar
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Zuo X, Cai J, Chen Z, Zhang Y, Wu J, Wu L, Wang J. Unplanned reoperation after radical gastrectomy for gastric cancer: causes, risk factors, and long-term prognostic influence. Ther Clin Risk Manag 2018; 14:965-972. [PMID: 29881278 PMCID: PMC5978462 DOI: 10.2147/tcrm.s164929] [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] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose Unplanned reoperation (URO) after radical gastrectomy for gastric cancer (GC) mostly results from serious postoperative complications. At present, there is still controversy over the predictive factors for URO. Our goal was to identify the risk factors for URO and to investigate its potential impact on long-term survival. Patients and methods We included 2,852 GC patients who underwent a gastrectomy. Multivariate logistic regression analyses were performed to determine the risk factors for URO. Patients were randomly selected from the non-URO group by 1:4 propensity score matching with multiple parameters with patients from the URO group. The survival disparity of 34 URO patients and 136 non-URO patients was examined using the Kaplan-Meier method and the multivariate Cox proportional hazard model. Results The incidence of URO was 1.4% (39/2, 852). The primary cause of URO was intra-abdominal bleeding (53.9%, 21/39). Multivariate logistic regression analyses revealed that male gender (OR = 4.630, 95% CI = 1.412-15.152, P = 0.011), diabetes (OR = 4.189, 95% CI = 1.705-10.290, P = 0.002), and preoperative hypoproteinemia (OR = 2.305, 95% CI = 1.079-4.923, P = 0.031) were independent risk factors for URO. With regard to early surgical outcomes, patients undergoing URO had a longer hospital stay (P < 0.001), higher incidence of postoperative complications (P < 0.001), and greater mortality (P < 0.001) compared with the non-URO group. No significant correlation was found between URO and cancer-specific survival in univariate (P = 0.275) and multivariate (P = 0.090) survival analyses. Conclusion Male gender, diabetes, and preoperative hypoproteinemia were suggested as independent risk factors for URO. URO was associated with longer hospital stay and increased perioperative mortality, but might not be correlated with long-term mortality.
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Affiliation(s)
- Xueliang Zuo
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Juan Cai
- Department of Oncology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhiqiang Chen
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China
| | - Yao Zhang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China
| | - Jian Wu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Liangyu Wu
- Department of General Surgery, Qingyang County People's Hospital, Qingyang, China
| | - Jinguo Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China
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Yang Z, Zeng H, Xia R, Liu Q, Sun K, Zheng R, Zhang S, Xia C, Li H, Liu S, Zhang Z, Liu Y, Guo G, Song G, Zhu Y, Wu X, Song B, Liao X, Chen Y, Wei W, Zhuang G, Chen W. Annual cost of illness of stomach and esophageal cancer patients in urban and rural areas in China: A multi-center study. Chin J Cancer Res 2018; 30:439-448. [PMID: 30210224 PMCID: PMC6129568 DOI: 10.21147/j.issn.1000-9604.2018.04.07] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective Stomach and esophageal cancer are imposing huge threats to the health of Chinese people whereas there were few studies on the financial burden of the two cancers. Methods Costs per hospitalization of all patients with stomach or esophageal cancer discharged between September 2015 and August 2016 in seven cities/counties in China were collected, together with their demographic information and clinical details. Former patients in the same hospitals were sampled to collect information on annual direct non-medical cost, indirect costs and annual number of hospitalization. Annual direct medical cost was obtained by multiplying cost per hospitalization by annual number of hospitalization. Annual cost of illness (ACI) was obtained by adding the average value of annual direct medical cost, direct non-medical cost and indirect cost, stratified by sex, age, clinical stage, therapy and pathologic type in urban and rural areas. Costs per hospitalization were itemized into eight parts to calculate the proportion of each part. All costs were converted to 2016 US dollars (1 USD=6.6423 RMB). Results Totally 19,986 cases were included, predominately male. Mean ages of stomach cancer and urban patients were lower than that of esophageal cancer and rural patients. ACI of stomach and esophageal cancer patients were $10,449 and $13,029 in urban areas, and $2,927 and $3,504 in rural areas, respectively. Greater ACI was associated with male, non-elderly patients as well as those who were in stage I and underwent surgeries. Western medicine fee took the largest proportion of cost per hospitalization. Conclusions The ACI of stomach and esophageal cancer was tremendous and varied substantially among the population in China. Preferential policies of medical insurance should be designed to tackle with this burden and further reduce the health care inequalities.
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Affiliation(s)
- Zhixun Yang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hongmei Zeng
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ruyi Xia
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an 710061, China
| | - Qian Liu
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an 710061, China
| | - Kexin Sun
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Rongshou Zheng
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Siwei Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Changfa Xia
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - He Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shuzheng Liu
- Henan Office for Cancer Control and Research, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Zhiyi Zhang
- Gansu Wuwei Tumor Hospital, Wuwei 733000, China
| | - Yuqin Liu
- Cancer Epidemiology Research Center, Gansu Provincial Cancer Hospital, Lanzhou 730050, China
| | - Guizhou Guo
- Linzhou Cancer Hospital, Linzhou 456500, China
| | - Guohui Song
- Cixian Cancer Institute, Handan 056500, China
| | - Yigong Zhu
- Luoshan Center for Disease Control and Prevention, Xinyang 464299, China
| | - Xianghong Wu
- Center for Disease Control and Prevention of Sheyang County, Sheyang 224300, China
| | - Bingbing Song
- Heilongjiang Office for Cancer Control and Research, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Xianzhen Liao
- Hunan Office for Cancer Control and Research, Hunan Cancer Hospital, Changsha 410006, China
| | - Yanfang Chen
- Yueyang Lou District Center for Disease Prevention and Control, Yueyang 414021, China
| | - Wenqiang Wei
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Guihua Zhuang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an 710061, China
| | - Wanqing Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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