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Ali K, Chervu NL, Sakowitz S, Bakhtiyar SS, Benharash P, Mohseni S, Keeley JA. Interhospital variation in the nonoperative management of acute cholecystitis. PLoS One 2024; 19:e0300851. [PMID: 38857278 PMCID: PMC11164333 DOI: 10.1371/journal.pone.0300851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/05/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile). METHODS All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH. RESULTS Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management. CONCLUSION We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.
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Affiliation(s)
- Konmal Ali
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil L. Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | | | - Peyman Benharash
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Jessica A. Keeley
- Division of Trauma and Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Los Angeles, CA, United States of America
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Horneck N, Ahmed I, Umemoto K, Ullal A, Vyas D. Medical Therapies to Conquer Surgical Diseases: Gallstone Disease May Be the Next Frontier. Int J Gen Med 2024; 17:21-27. [PMID: 38204495 PMCID: PMC10776917 DOI: 10.2147/ijgm.s434877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Over the past half century, diseases that were predominantly treated surgically have transitioned to less invasive medical therapies. Such diseases that are now effectively treated with medicine are (1) peptic ulcer disease (PUD), (2) coronary artery disease (CAD), and (3) gastrointestinal stromal tumors (GISTs). Likewise, gallstone disease may soon follow this trend. Currently, the gold standard treatment of symptomatic gallstones is laparoscopic cholecystectomies. Though one of the most common surgeries in the United States, certain cases of acute and gangrenous cholecystitis can be some of the most difficult surgeries to perform. Advancements in neutrophil extracellular trap (NET) inhibitor medical therapies will alter gallstone disease management and the mainstream role of surgical interventions. This focus on less invasive therapies will greatly impact the quality of patient care, financial obligations, and even resident training opportunities.
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Affiliation(s)
- Nadine Horneck
- Department of Surgery, California Northstate University, College of Medicine, Elk Grove, CA, USA
| | - Ifrah Ahmed
- Department of Surgery, California Northstate University, College of Medicine, Elk Grove, CA, USA
| | - Kayla Umemoto
- Department of Surgery, California Northstate University, College of Medicine, Elk Grove, CA, USA
| | - Anvay Ullal
- Department of Surgery, California Northstate University, College of Medicine, Elk Grove, CA, USA
| | - Dinesh Vyas
- Department of Surgery, California Northstate University, College of Medicine, Elk Grove, CA, USA
- Department of Surgery, Dameron Adventist Hospital, Stockton, CA, USA
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Tian WM, Chang D, Pressley M, Muhammed M, Fong P, Webster W, Herbert G, Gallagher S, Watters CR, Yoo JS, Zani S, Agarwal S, Allen PJ, Seymour KA. Development of a prospective biliary dashboard to compare performance and surgical cost. Surg Endosc 2023; 37:8829-8840. [PMID: 37626234 DOI: 10.1007/s00464-023-10376-4] [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: 04/03/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system. METHODS Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes. RESULTS Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers. CONCLUSION Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.
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Affiliation(s)
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, NC, USA
| | - Melissa Pressley
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Makala Muhammed
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Philip Fong
- Department of Surgery, Duke University, Durham, NC, USA
| | - Wendy Webster
- Department of Surgery, Duke University, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University, Durham, NC, USA
| | | | | | - Jin S Yoo
- Department of Surgery, Duke University, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Peter J Allen
- Department of Surgery, Duke University, Durham, NC, USA
| | - Keri A Seymour
- Department of Surgery, Duke University, Durham, NC, USA.
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Dodd WS, Small CN, Goutnik M, Laurent D, Crossman J, Motwani K, Lucke-Wold B, Polifka AJ, Koch M, Brzezicki G, Hoh BL, Chalouhi N. Cost Comparison: Evaluating Transfemoral and Transradial Access for Diagnostic Cerebral Angiography. STROKE (HOBOKEN, N.J.) 2023; 3:e000428. [PMID: 36743257 PMCID: PMC9893797 DOI: 10.1161/svin.122.000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Modern medicine necessitates the delivery of increasingly complex health care while minimizing cost. Transradial access (TRA) for neuroendovascular procedures is becoming more common as accumulating data demonstrate fewer complications, improved patient satisfaction, and high rates of treatment success compared with the transfemoral access (TFA) approach; however, disparities in cost between these approaches remain unclear. We compared supply and equipment costs between TRA and TFA for diagnostic cerebral angiography and evaluate the specific items that account for these differences. METHODS We reviewed all adult patients who underwent diagnostic cerebral angiography from July 1, 2019 to December 31, 2019. Data related to patient demographics, vascular access site, catheters used, cost of catheters, arterial access sheath use, cost of sheaths, closure devices used, and cost of closure devices were collected. RESULTS The transradial approach resulted in higher price of radial access sheath; however, the overall cost of closure devices was much lower in TRA group than in the TFA cohort. There was no significant difference in the cost of catheters. Overall, the total supply costs for TRA cerebral angiography were significantly lower than those of TFA cerebral angiography. The relative materials cost difference of using TRA was 20.9%. CONCLUSION This study is the first itemized materials cost analysis of TRA versus TFA cerebral angiography. TRA necessitates the use of a more expensive access sheath device; however, this cost is offset by the increased cost of devices used for femoral arteriotomy closure. Overall, the supply and equipment costs were significantly lower for TRA than TFA.
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Affiliation(s)
- William S Dodd
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Coulter N Small
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Michael Goutnik
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Dimitri Laurent
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - James Crossman
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Kartik Motwani
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Grzegorz Brzezicki
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
| | - Nohra Chalouhi
- Department of Neurosurgery, University of Florida, Gainesville, FL (W.S.D., C.N.S., M.G., D.L., J.C., K.M., B.L.-W., A.J.P., M.K., B.L.H., N.C.); Department of Neurosurgery, University of Florida Health, Jacksonville, FL (G.B.)
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Kano D, Hu C, Thornley CJ, Cruz CY, Soper NJ, Preston JF. Risk factors associated with venous thromboembolism in laparoscopic surgery in non-obese patients with benign disease. Surg Endosc 2023; 37:592-606. [PMID: 35672502 DOI: 10.1007/s00464-022-09361-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 05/22/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Few studies have focused on intraoperative positioning as a risk factor for venous thromboembolism (VTE). Positioning that places the legs in a dependent position may be a risk factor. We theorized that the reverse-Trendelenburg position specifically would increase the risk of postoperative VTE. METHODS AND PROCEDURES 374,017 subjects undergoing laparoscopic surgery in the 2015-2018 NSQIP database were included. Diagnosis of cancer and BMI ≥ 30 were excluded. Subjects were grouped based on positioning: reverse-Trendelenburg (RT), supine (S), and Trendelenburg (T). RESULTS The RT, S, and T groups consisted of 117,887, 66,511, and 189,619 subjects, respectively. Overall median BMI was 25.7, and 82.8% of subjects were non-smokers. VTE within 30 days postoperative was seen in 0.25% RT, 0.23% S, and 0.4% T (p < 0.0001); 30-day mortality was 0.34% RT, 0.25% S, and 0.19% T (p < 0.0001). After adjusting for potential confounders and other risk factors, RT position was associated with a lower risk of VTE compared to S (OR 1.49 with 95% CI 1.16, 1.93) and T (OR 1.34 with 95% CI 1.15, 1.56) positions. VTE risk was significantly different across the three groups (p = 0.0001). Inpatient procedures had a higher VTE risk vs outpatient (OR 2.49 with 95% CI 2.10, 2.95). Increasing operative time was associated with higher VTE risk [4th (> 106 min) vs 1st (≤ 40 min) quartiles (OR 3.54 with 95% CI 2.79, 4.48)]. CONCLUSIONS Among other risk factors, inpatient procedures and longer operative times are associated with higher VTE risk in laparoscopic surgery performed for benign disease in non-obese patients. The risk was significantly different across the three positioning groups with lowest risk in the RT group and highest risk in the S group.
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Affiliation(s)
- Daiji Kano
- Phoenix Integrated Surgical Residency, 1111 E McDowell Rd, Phoenix, AZ, 85006, USA.
| | - Chengcheng Hu
- University of Arizona Mel and Enid Zuckerman College of Public Health-Phoenix, Phoenix, USA
| | - Caitlin J Thornley
- Phoenix Integrated Surgical Residency, 1111 E McDowell Rd, Phoenix, AZ, 85006, USA
| | - Cecilia Y Cruz
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
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Variability in hospital costs for short stay emergent laparoscopic appendectomy. Surg Open Sci 2022; 10:223-227. [DOI: 10.1016/j.sopen.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
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Green RL, Dunham P, Kling SM, Kuo LE. Not Clearing the Air: Hospital Price Transparency for a Laparoscopic Cholecystectomy. J Surg Res 2022; 280:501-509. [PMID: 36081309 DOI: 10.1016/j.jss.2022.07.037] [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: 03/01/2022] [Revised: 06/17/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In 2019, Centers for Medicare and Medicaid Services (CMS) established a new requirement that all hospitals publish information on the standard costs of services provided. Increased price transparency allows patients to compare healthcare costs and make informed decisions about their care. We investigated compliance with this rule with regards to laparoscopic cholecystectomy, a commonly performed operation and one of the 70 shoppable services (SSs) included in the CMS requirement, among prominent hospitals in the United States. METHODS The 2021-2022 US News "Best Hospitals for Gastroenterology and GI Surgery" was used to identify the top 50 hospitals for gastrointestinal surgery. Each hospital's website was assessed for the presence of a machine-readable file (MRF) as required by CMS. Each MRF was then evaluated for inclusion of all seven required elements: description of item/service, gross charge, payer-specific negotiated charge, deidentified minimum and maximum negotiated charges, discounted cash price, and billing code. The presence of a consumer-friendly display of SSs was also evaluated. The Current Procedural Terminology code 47562 (removal of gallbladder with an endoscope) was used to search for all six required elements: payer-specific negotiated charge, discounted cash price, de-identified minimum and maximum negotiated charges, campus location of the SS, and billing code. The SS display was further evaluated for provision of additional information on ancillary charges, which are recommended but not required. The MRF and SS were also evaluated for accessibility and date of last update. Hospitals were analyzed according to rank. Compliance with CMS requirements was compared between hospitals. RESULTS Fifty one hospitals were included. Of these 51 hospitals, one (2%) provided all the required information for both MRF and SS, 44 (86%) did not provide all necessary components of both the MRF and SS, six (12%) had all necessary elements of an MRF only, and two (4%) had all necessary elements of the SS only. The MRF was accessible in 80% (41) of studied hospitals and 76% (39) provided a gross charge but just 35% (18) of hospitals included the discounted cash price. The SS specified location for all hospitals, indicated a billing code in 96% (49), and provided a payer-specific charge in 96% (48), but less often provided de-identified minimum (30; 59%) and maximum (30; 59%) charges. Thirty nine (76%) hospitals reported that the listed price included an ancillary charge. There was no significant difference between hospitals in having all required elements of both the MRF and SS or the MRF only or SS only. CONCLUSIONS Hospitals are providing healthcare consumers with standard charge information, although with significant variation in what is disclosed. There is no association between hospital reputation and provision of standard charge information.
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Affiliation(s)
- Rebecca L Green
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania.
| | - Patricia Dunham
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Sarah M Kling
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Lindsay E Kuo
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
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Malhotra L, Pontarelli EM, Grinberg GG, Isaacs RS, Morris JP, Yenumula PR. Cost analysis of laparoscopic appendectomy in a large integrated healthcare system. Surg Endosc 2021; 36:800-807. [PMID: 33502616 DOI: 10.1007/s00464-020-08266-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/22/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Healthcare expenditure is on the rise placing greater emphasis on operational excellence, cost containment, and high quality of care. Significant variation is seen in operating room (OR) costs with common surgical procedures such as laparoscopic appendectomy. Surgeons can influence cost through the selection of instrumentation for common surgical procedures such as laparoscopic appendectomy. We aimed to quantify the cost of laparoscopic appendectomy in our healthcare system and compare cost variations to operative times and outcomes. METHODS AND PROCEDURES We performed a retrospective review of laparoscopic appendectomies in a large regional healthcare system during one-year period (2018). Operating room supply costs and procedure durations were obtained for each hospital. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) outcomes and demographics were compared to the costs for each hospital. RESULTS A total of 4757 laparoscopic appendectomies were performed at 20 hospitals (27 to 522 per hospital) by 233 surgeons. The average supply cost per case ranged from $650 to $1067. Individual surgeon cost ranged from $197 to $1181. The average operative time was 41 min (range 33 to 60 min). There was no association between lower cost and longer operative time. The patient demographics and comorbidities were similar between sites. There were no significant differences in postoperative complications between high- and low-cost centers. The items with the greatest increase in cost were single-use energy devices (SUD) and endoscopic stapler. We estimate that a saving of over $417 per case is possible by avoiding the use of energy devices and may be as high as $ 984 by adding selective use of staplers. These modifications would result in an annual savings of $1 million for our health system and more than $ 125 million nationwide. CONCLUSION Performing laparoscopic appendectomy with reusable instruments and finding alternatives to expensive energy devices and staplers can significantly decrease costs and does not increase operative time or postoperative complications.
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Affiliation(s)
- Lavina Malhotra
- Kaiser Permanente South Sacramento, 6600 Bruceville Rd, Sacramento, CA, 95823, USA
| | | | - Gary G Grinberg
- Kaiser Permanente South Sacramento, 6600 Bruceville Rd, Sacramento, CA, 95823, USA
| | - Richard S Isaacs
- Kaiser Permanente South Sacramento, 6600 Bruceville Rd, Sacramento, CA, 95823, USA
| | - James P Morris
- Kaiser Permanente South San Francisco, South San Francisco, CA, USA
| | - Pandu R Yenumula
- Kaiser Permanente South Sacramento, 6600 Bruceville Rd, Sacramento, CA, 95823, USA.
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Kokoroskos N, Peponis T, Lee JM, El Hechi M, Naar L, Elahad JA, Nederpelt C, Bonde A, Meier K, Mendoza A, King D, Fagenholz P, Kaafarani H, Velmahos G, Saillant N. Gallbladder wall thickness as a predictor of intraoperative events during laparoscopic cholecystectomy: A prospective study of 1089 patients. Am J Surg 2020; 220:1031-1037. [PMID: 32178838 DOI: 10.1016/j.amjsurg.2020.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/24/2020] [Accepted: 03/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has a wide range of technical difficulty. Preoperative risk stratification is essential for adequate planning and patient counseling. We hypothesized that gallbladder wall thickness (GWT) is more objective marker than symptom duration in predicting complexity, as determined by operative time (OT), intraoperative events (IE), and postoperative complications. METHODS All adult patients who underwent LC during 2010-2018 were included. GWT, measured on imaging and on the histopathologic exam, was divided into three groups: <3 mm (normal), 3-7 mm and >7 mm. Univariate and multivariable analyses were performed to determine the association between GWT and 1) operative time, 2) the incidence of IE and 3) postoperative outcomes. RESULTS A total of 1089 patients, subjects to LC, were included in the study. GWT was positively correlated with median OT (p < 0.001), the incidence of IE (p < 0.001) and median length of hospital stay (p < 0.001). GWT independently predicted IE (OR = 2.1 95% CI: 1.3-3.4) and outperformed symptom duration, which was not significantly associated with any of the outcomes (p = 0.7). CONCLUSIONS GWT independently predicted IE and may serve as an objective marker of LC complexity.
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Affiliation(s)
- Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Thomas Peponis
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jae Moo Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joana Abed Elahad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Charlie Nederpelt
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander Bonde
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Karien Meier
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David King
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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