Nationwide inpatient sample: have antireflux procedures undergone regionalization?

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

Background

The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force.

Methods

An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence.

Results

Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia.

Conclusion

A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.

Laparoscopic fundoplication performed in community hospital settings: A protocol for systematic review

BACKGROUND

Laparoscopic fundoplication (LF) is well-established as the surgical intervention of choice for management of refactory gastro-esophageal reflux disease. Much of its success lies in the reported benefits in symptom control outlined by the postoperative patient. It is unclear whether patient-reported outcomes differ according to the institution type providing care. This review aimed to address this knowledge gap by reviewing the available evidence examining patient-reported outcomes of LF in non-metropolitan centers.

OBJECTIVES

To investigate patient-reported outcomes of LF performed in regional or community-based hospitals.

DATA SOURCES

Four electronic databases, and citations of relevant articles.

STUDY ELIGIBILITY CRITERIA

Only studies that separately reported patient-reported outcomes of LF performed in regional or community hospitals were included; papers deemed to be unclear about the type of facility in which LF surgeries were performed, or in which data from LF surgeries performed in regional/community hospitals was combined with data from major metropolitan hospitals, were excluded.

STUDY APPRAISAL

Only studies that were graded as fair or good using Quality Assessment Tool for Observational Cohort and Cross-sectional studies were eligible for inclusion in this review. Seven studies were then eligible for inclusion, all of which were observational cohort studies with 6 of the studies reporting on a single intervention arm.

RESULTS

Seven observational cohort studies were included in the review, with a combined total of 1071 patients who underwent LF at non-metropolitan centers. Of these, data was collected for 742 patients, yielding an overall response rate of 69.3%. All 7 studies assessed patients' post-operative outcomes through questionnaires that were based on a modified Likert scale or a similar tool. Overall patient satisfaction was high (86%) and a significant majority of patients stated they would recommend the procedure to others (93.3%). Post-operative prevalence of reflux and dysphagia compared favorably to rates generally reported in the literature (11.9% and 17.6% respectively). Further research is required to ascertain the safety of performing these procedures in non-metropolitan hospitals.

CONCLUSION

Current evidence suggests that patient-reported outcomes are favorable for patients undergoing LF in community settings, and are broadly comparable to those undergoing LF in tertiary-level centers.

Complications Following Robotic Hiatal Hernia Repair Are Higher Compared to Laparoscopy

BACKGROUND

The use of robotic platforms in surgery is becoming increasingly common in both practice and residency training. In this study, we compared the perioperative outcomes between robotic platforms and traditional laparoscopy in paraesophageal hernia repair.

METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample for the period of 2010-2015. Adult patients (≥18 years old) who underwent laparoscopic or robotic paraesophageal hernia repairs were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the effects of robotic surgery on patient outcomes.

RESULTS

A total of 168,329 patients were included in the study. The overall adjusted rate of complications was significantly higher in patients who underwent robotic paraesophageal hernia (PEH) repair compared to laparoscopic PEH OR (95% CI) = 1.17 (1.07, 1.27). Specifically, respiratory failure OR (95% CI) = 1.68 (1.37, 2.05) and esophageal perforation OR (95% CI) = 2.19 (1.42, 3.93) were higher in robotic PEH patients. A subset analysis was performed looking at high-volume centers (>20 operations per year), and, although the risk of complications was lower in the high volume centers compared to intermediate volume centers, complication rates were still significantly higher in the robotic surgery group compared to laparoscopic. Overall charges per surgery were significantly higher in the robotic group.

CONCLUSION

Robotic PEH repair is associated with significantly more complications compared to laparoscopic paraesophageal hernia repair even in high-volume centers.

Effect of On-Site Cardiac Surgery Program on General Thoracic Surgery Outcomes

OBJECTIVE

Limited data exist exploring the relationship between multispecialty surgical collaboration and outcomes in general thoracic surgery. To address this, the Nationwide Inpatient Sample (NIS) was analyzed to determine whether the presence of an on-site cardiac surgery program is associated with improved general thoracic surgery outcomes.

METHODS

The NIS (1999-2008) was utilized to identify 389,959 patients who had a lobectomy, pneumonectomy, or esophagectomy. Short-term outcomes of patients undergoing these procedures were compared between hospitals with and without an on-site cardiac surgery program. Univariate and multivariate analyses were performed to determine patient and hospital predictors of mortality and morbidity.

RESULTS

During the study period, patients undergoing lobectomy (n = 314,130), pneumonectomy (n = 34,860), or esophagectomy (n = 40,969) were identified. Univariate analysis demonstrated lower mortality for lobectomy (P < 0.001) and esophagectomy (P < 0.001) but not pneumonectomy (P = 0.344) in hospitals with a cardiac surgery program. All-cause morbidity was significantly lower for all 3 procedures in hospitals with a cardiac surgery program. However, multivariate analysis demonstrated that a cardiac surgery program was not an independent predictor when adjusted for known confounders, particularly procedure volume and hospital academic teaching status.

CONCLUSIONS

The presence of an on-site cardiac surgery program is not in and of itself associated with improved general thoracic surgery outcomes. The presence of a cardiac surgery program is likely a surrogate for other known predictors of improved outcomes such as hospital teaching status and procedure volume.

Antireflux Surgery in the USA: Influence of Surgical Volume on Perioperative Outcomes and Costs-Time for Centralization?

BACKGROUND

Few studies have analyzed the relationship between surgical volume and outcomes after antireflux procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs for patients undergoing surgery for gastroesophageal reflux disease.

METHODS

We analyzed the National Inpatient Sample (period 2000-2013). Adult patients (≥18 years old) with gastroesophageal reflux disease who underwent fundoplication were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (<10 operations/year), intermediate (10-25 operations/year), or high (>25 operations/year). We performed multivariable logistic regression models to assess the effect of surgical volume on patient outcomes.

RESULTS

The studied cohort comprised 75,544 patients who had antireflux surgery. When operations performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55 days longer, respectively). There was an increase in charges of 5120 dollars per patient at low-volume centers, and 4010 dollars per patient at intermediate-volume centers.

CONCLUSIONS

When antireflux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital stay is shorter, and costs for the healthcare system are decreased.

Alternative therapies for GERD: a way to personalized antireflux surgery

Gastroesophageal reflux disease (GERD) is a common disorder, known to affect about 20% of the Western population. Although conventional medical or surgical treatment has proven effective, there is certainly room for improvements. As only 10% of GERD patients are finally treated by antireflux surgery, a large therapeutic window exists. This treatment gap consists of patients who are not effectively treated with proton pump inhibitor but do not want to run the potential risks of conventional surgery. During the last two decades, several novel and intriguing options for the surgical treatment of GERD have been introduced and found their way into clinical use. The following summary will give an update of certain alternative therapeutic options to treat GERD or its pathological consequences.

Variation in laparoscopic anti-reflux surgery across England: a 5-year review

Background

Laparoscopic anti-reflux surgery (LARS) remains central to the management of gastro-oesophageal reflux disease but the scale and variation in provision in England is unknown. The aims of this study were firstly to examine the processes and outcomes of anti-reflux surgery in England and compare them to national guidelines and secondly to explore potential variations in practice nationally and establish peer benchmarks.

Methods

All adult patients who underwent LARSin England during the Financial years FY 2011/2012–FY 2016/2017 were identified in the Surgeon’s Workload Outcomes and Research Database (SWORD), which is based on the Hospital Episode Statistics (HES) data warehouse. Outcomes included activity volume, day-case rate, short-stay rate, 2- and 30-day readmission rates and 30-day re-operation rates. Funnel plots were used to identify national variation in practice.

Results

In total, 12,086 patients underwent LARS in England during the study period. The operation rate decreased slightly over the study period from 5.2 to 4.6 per 100,000 people. Most outcomes were in line with national guidelines including the conversion rate (0.76%), 30-day re-operation rate (1.43%) and 2- and 30-day readmission rates (1.65 and 8.54%, respectively). The day-case rate was low but increased from 7.4 to 15.1% during the 5-year period. Significant variation was found, particularly in terms of hospital volume, and day-case, short-stay and conversion rates.

Conclusion

Although overall outcomes are comparable to studies from other countries, there is significant variation in anti-reflux surgery activity and outcomes in England. We recommend that units use these data to drive local quality improvement efforts.

Paraesophageal Hernia Repair in the USA: Trends of Utilization Stratified by Surgical Volume and Consequent Impact on Perioperative Outcomes

BACKGROUND

The impact of surgical volume on perioperative results after a paraesophageal hernia (PEH) repair has not yet been analyzed. We sought to characterize the trend of utilization of this procedure stratified by surgical volume in the USA, and analyze its impact on perioperative outcomes.

METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥18 years old) who underwent PEH repair were included. Surgical volume was categorized as small (<6 operations/year), intermediate (6-20 operations/year), or high (>20 operations/year). Multivariable linear and logistic regression models were used to assess the effect of surgical volume on patient outcomes.

RESULTS

A total of 63,812 patients were included. Over time, the rate of procedures across high-volume centers increased from 65.8 to 94.4%. The use of the laparoscopic approach was significantly different among the groups (small volume 38.4%; intermediate volume 41.8%; high volume 67.4%; p < 0.0001). Patients undergoing PEH repair at high-volume hospitals were less likely to experience postoperative bleeding, cardiac failure, respiratory failure, and shock. On average, patients at low- and intermediate-volume hospitals stayed 0.8 and 0.6 days longer, respectively.

CONCLUSIONS

A spontaneous centralization towards high-volume centers for PEH repair has occurred in the last decade. This trend is beneficial for patients as it is associated with higher rates of laparoscopic operations, decreased surgical morbidity, and a shorter length of hospital stay.

National Trends in the Surgical Treatment of Ovarian Torsion in Children: An Analysis of 2041 Pediatric Patients Utilizing the Nationwide Inpatient Sample

The aim of this study was to evaluate the national trends in surgical management of ovarian torsion (OT) in children. The Nationwide Inpatient Sample was queried from 1998 to 2011 for females less than 18 years of age with OT. Patients were stratified into three treatment groups: oophorectomy (OO), oophoropexy, or release of torsion (RT) alone. There were 2041 patients with OT, of which 1598 (78%) underwent OO, 126 (6%) oophoropexy, and 317 (15%) RT. RT significantly increased from 1998 to 2011 (9% vs 25%; P < 0.05). At nonteaching hospitals, there were higher rates of OO (89.3% vs 79.5%; P < 0.05) and lower rates of RT (10.7% vs 20.5%; P < 0.05) compared with teaching hospitals. RT was performed at a higher rate in Northeast United States compared with the South (22.7% vs 14.2%; P < 0.05). Girls presenting at nonteaching hospitals and the South had increased odds of undergoing OO compared with those presenting at teaching hospitals and the Northeast ( P < 0.05). Although ovarian conservation for OT in children is more often performed in the Northeast United States and at teaching hospitals, this large population-based study demonstrates OO remains the most common surgical management for OT in the United States.

Nationwide outcomes of nontrauma splenectomy

INTRODUCTION

Due to the impact of LeapFrog and many scientific publications, regionalization for solid-organ operations gained momentum in the early 2000s. This study examines the effects of regionalization for medically indicated, nontrauma splenectomies (NTSs) in the USA.

METHODS

The Nationwide Inpatient Sample (NIS) data were analyzed for NTS based on International Classification of Disease Ninth Revision Clinical Modification codes for 1998–1999 (the 1990s) and 2008–2009 (the 2000s). The hospitals in the NIS were stratified by volume and divided into high volume (HV), medium volume, and low-volume (LV) terciles based on the annual volume of splenectomies performed (<5, 5–10, and 11+, respectively). Demographics, comorbidities, complications, admission status, and in-patient mortality were recorded. Univariate and multivariate statistical analyses were utilized.

RESULTS

NIS recorded 4,293 NTS performed in the 1990s and 3,384 in the 2000s. Despite the decrease in operative volume, regionalization did not occur: in the first decade 30, 37, and 33 % of cases occurred in LV center (LVC), medium volume center, and HV center (HVC), respectively, compared with 34, 30, and 36 % in the second decade (p < 0.001). Patients were older in low-volume hospitals (LVC) than in high-volume hospitals (HVC) in both decades (in the 1990s: 45.3 vs. 52.7 years, p < 0.001; in the 2000s: 49.1 vs. 54.5 years, p < 0.001). The Charlson Comorbidity Index scores were not different in LVC compared with HVC in both decades (the 1990s: 1.31 vs. 1.23, p = 0.73; the 2000s: 1.54 vs. 1.41, p = 0.72). In both decades, LVC had more emergent admissions than HVC (20.3 vs. 16.8 %, p = 0.03; 28.8 vs. 19.5 %, p < 0.001). Complication rates were higher in LVC in both decades (the 1990s: 16.9 vs. 13.6 %, p = 0.02; the 2000s: 19.8 vs. 15.5 %, p = 0.006). Mortality was not different for HVC and LVC in both decades (the 1990s: 3.75 vs. 4.27, p = 0.49; the 2000s: 2.94 vs. 4.03, p = 0.15).

CONCLUSIONS

NTS has not been affected by regionalization, which is dissimilar to other solid-organ abdominal procedures. Indeed, the benefit of regionalization for splenectomy has not been established.