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Farah A. A Letter to the editor: Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland. Surgeon 2024:S1479-666X(24)00118-5. [PMID: 39366814 DOI: 10.1016/j.surge.2024.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 09/27/2024] [Indexed: 10/06/2024]
Affiliation(s)
- Amir Farah
- Medical College of Wisconsin, Department of Surgery, Division of Trauma and Acute Care Surgery, Milwaukee, WI, USA.
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van den Berg R, den Hartog FPJ, Menon AG, Tanis PJ, Gillion JF. Is surgeon annual case volume related with intra and postoperative complications after ventral hernia repair? Uni- and multivariate analysis of prospective registry-based data. Hernia 2024; 28:1935-1944. [PMID: 39112727 PMCID: PMC11449983 DOI: 10.1007/s10029-024-03129-2] [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: 05/23/2024] [Accepted: 07/28/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Literature on a potential relationship between surgeon case volume and intra- or postoperative complications after ventral hernia repair remains scarce. METHODS Patients who underwent ventral hernia repair between 2011 and 2023 were selected from the prospectively maintained French Hernia-Club Registry. Outcome variables were: intraoperative events, postoperative general complications, surgical site occurrences, surgical site infections, length of intensive care unit (ICU), and patient-reported scar bulging during follow-up. Surgeons' annual case volume was categorized as 1-5, 6-50, 51-100, 101-125, and > 125 cases, and its association with outcome volume was evaluated using uni- and multivariable analyses. RESULTS Over the study period, 199 titular or temporary members registered 15,332 ventral hernia repairs, including 7869 primary, 6173 incisional, and 212 parastomal hernia repairs. In univariate analysis, surgeons' annual case volume was significantly related with all the postoperative studied outcomes. After multivariate regression analysis, annual case volume remained significantly associated with intra-operative complications, postoperative general complications and length of ICU stay. A primary repair was independently associated with fewer intra- and post-operative complications. CONCLUSION In the present multivariable analysis of a large registry on ventral hernia repairs, higher surgeon annual case volume was significantly related with fewer postoperative general complications and a shorter length of stay, but not with fewer surgical site occurrences, nor with less patient-reported scar bulging. Factors in the surgeons' case mix such as the type of hernia have significant impact on complication rates.
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Affiliation(s)
- R van den Berg
- Department of Surgery, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - F P J den Hartog
- Department of Surgery, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - A G Menon
- Department of Surgery, IJsselland Hospital, Capelle Aan Den IJssel, The Netherlands
| | - P J Tanis
- Department of Surgery, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - J F Gillion
- Hôpital Privé d'Antony, 1 Rue Velpeau, 92160, Antony, France
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Chan KY, Raftery N, Abdelhafiz T, Rayis A, Johnston S. Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland. Surgeon 2024; 22:92-98. [PMID: 37838612 DOI: 10.1016/j.surge.2023.09.008] [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: 05/28/2023] [Revised: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs). METHODS All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis. RESULTS A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002). CONCLUSION Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.
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Affiliation(s)
- Kin Yik Chan
- Department of Surgery, Midland Regional Hospital Tullamore, Co.Offaly, R35NY51, Ireland.
| | - Nicola Raftery
- Department of Surgery, Midland Regional Hospital Tullamore, Co.Offaly, R35NY51, Ireland
| | - Tarig Abdelhafiz
- Department of Surgery, Midland Regional Hospital Tullamore, Co.Offaly, R35NY51, Ireland
| | - Abubakr Rayis
- Department of Surgery, Midland Regional Hospital Tullamore, Co.Offaly, R35NY51, Ireland
| | - Sean Johnston
- Department of Surgery, Midland Regional Hospital Tullamore, Co.Offaly, R35NY51, Ireland
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Adams ST, Scott M, West C, Walsh CJ. Separating the components of an abdominal wall fellowship. Ann R Coll Surg Engl 2024; 106:2-8. [PMID: 36374299 PMCID: PMC10757876 DOI: 10.1308/rcsann.2022.0058] [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] [Accepted: 04/19/2022] [Indexed: 01/02/2024] Open
Abstract
Complex abdominal wall reconstruction is an emerging subspecialty yet, despite the abundance of abdominal wall hernias requiring treatment and the increasing complexity of this type of surgery, there are few opportunities for surgeons to gain subspecialist training in this field. In this paper we discuss the need for focused training in complex abdominal wall reconstruction, outline some of the problems that may be hindering the availability of such opportunities and propose potential solutions to these issues.
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Affiliation(s)
- ST Adams
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
- Wirral University Teaching Hospitals (WUTH) NHS Foundation Trust, UK
| | - M Scott
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - C West
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - CJ Walsh
- Wirral University Teaching Hospitals (WUTH) NHS Foundation Trust, UK
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Shmelev A, Olsen MA, Bray JO, Nikolian VC. Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction. Surg Endosc 2023; 37:7582-7590. [PMID: 37460820 DOI: 10.1007/s00464-023-10286-5] [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: 04/01/2023] [Accepted: 07/05/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC). METHODS All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated. RESULTS A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5 cm vs 10.5 cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%). CONCLUSIONS High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.
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Affiliation(s)
- Artem Shmelev
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Molly A Olsen
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jordan O Bray
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L 233A, Portland, OR, 97239, USA
| | - Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L 233A, Portland, OR, 97239, USA.
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Katzen M, Sacco J, Ku D, Scarola GT, Colavita PD, Heniford BT, Augenstein VA. The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis. Surg Endosc 2023:10.1007/s00464-023-09867-1. [PMID: 37277520 DOI: 10.1007/s00464-023-09867-1] [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: 07/30/2022] [Accepted: 01/04/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.
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Affiliation(s)
- Michael Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Jana Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - David Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA.
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Witvoet S, de Massari D, Shi S, Chen AF. Leveraging large, real-world data through machine-learning to increase efficiency in robotic-assisted total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07314-1. [PMID: 36650339 DOI: 10.1007/s00167-023-07314-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE Increased operative time can be due to patient, surgeon and surgical factors, and may be predicted by machine learning (ML) modeling to potentially improve staff utilization and operating room efficiency. The purposes of our study were to: (1) determine how demographic, surgeon, and surgical factors affected operative times, and (2) train a ML model to estimate operative time for robotic-assisted primary total knee arthroplasty (TKA). METHODS A retrospective study from 2007 to 2020 was conducted including 300,000 unilateral primary TKA cases. Demographic and surgical variables were evaluated using Wilcoxon/Kruskal-Wallis tests to determine significant factors of operative time as predictors in the ML models. For the ML analysis of robotic-assisted TKAs (> 18,000), two algorithms were used to learn the relationship between selected predictors and operative time. Predictive model performance was subsequently assessed on a test data set comparing predicted and actual operative time. Root mean square error (RMSE), R2 and percentage of predictions with an error < 5/10/15 min were computed. RESULTS Males, BMI > 40 kg/m2 and cemented implants were associated with increased operative time, while age > 65yo, cementless, and high surgeon case volume had reduced operative time. Robotic-assisted TKA increased operative time for low-volume surgeons and decreased operative time for high-volume surgeons. Both ML models provided more accurate operative time predictions than standard time estimates based on surgeon historical averages. CONCLUSIONS This study demonstrated that greater surgeon case volume, cementless fixation, manual TKA, female, older and non-obese patients reduced operative time. ML prediction of operative time can be more accurate than historical averages, which may lead to optimized operating room utilization. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Sarah Shi
- Stryker Corporation, Mahwah, NJ, USA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Chaves CER, Girón F, Conde D, Rodriguez L, Venegas D, Vanegas M, Pardo M, Núñez-Rocha RE, Vargas F, Navarro J, Ricaurte A. Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group. Sci Rep 2022; 12:18325. [PMID: 36316384 PMCID: PMC9622848 DOI: 10.1038/s41598-022-22062-x] [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: 02/11/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
Abstract
Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014-December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m2. Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3-1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3-0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.
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Affiliation(s)
- Carlos Eduardo Rey Chaves
- grid.41312.350000 0001 1033 6040School of Medicine, Pontificia Universidad Javeriana, Calle 6A #51a - 48, 111711 Bogotá D.C., Colombia
| | - Felipe Girón
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia ,grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Danny Conde
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia ,grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Lina Rodriguez
- grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - David Venegas
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Marco Vanegas
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Manuel Pardo
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Ricardo E. Núñez-Rocha
- grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Felipe Vargas
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia ,grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Jorge Navarro
- grid.41312.350000 0001 1033 6040School of Medicine, Pontificia Universidad Javeriana, Calle 6A #51a - 48, 111711 Bogotá D.C., Colombia ,Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia
| | - Alberto Ricaurte
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Rosen MJ, Krpata DM, Petro CC, Carbonell A, Warren J, Poulose BK, Costanzo A, Tu C, Blatnik J, Prabhu AS. Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial. JAMA Surg 2022; 157:293-301. [PMID: 35044431 PMCID: PMC8771431 DOI: 10.1001/jamasurg.2021.6902] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias. OBJECTIVE To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias. DESIGN, SETTING, AND PARTICIPANTS This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021. INTERVENTIONS Retromuscular synthetic or biologic mesh at the time of fascial closure. MAIN OUTCOMES AND MEASURES The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs. RESULTS A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001). CONCLUSIONS AND RELEVANCE Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02451176.
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Affiliation(s)
- Michael J. Rosen
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alfredo Carbonell
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Jeremy Warren
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Benjamin K. Poulose
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus
| | - Adele Costanzo
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffrey Blatnik
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ajita S. Prabhu
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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Wirth K, Näpflin M, Graber SM, Blozik E. Does hospital volume affect outcomes after abdominal cancer surgery: an analysis of Swiss health insurance claims data. BMC Health Serv Res 2022; 22:262. [PMID: 35219332 PMCID: PMC8881861 DOI: 10.1186/s12913-022-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Medical treatment quality has been shown to be better in high volume than in low volume hospitals. However, this relationship has not yet been confirmed in abdominal cancer in Switzerland and is relevant for referral of patients and healthcare planning. Thus, the present study investigates the association between hospital volumes for surgical resections of colon, gastric, rectal, and pancreatic carcinomas and outcomes. Methods This retrospective analysis is based on anonymized claims data of patients with mandatory health insurance at Helsana Group, a leading health insurance in Switzerland. Outcome parameters were length of hospital stay, mortality and cost during the inpatient stay as well as at 1-year follow-up. Hospital volume information was derived from the Quality Indicators dataset provided by the Swiss Federal Office of Public Health. The impact of hospital volume on the different treatment outcomes was statistically tested using generalized estimating equations (GEE) models, taking into account the non-independence of observations from the same hospital. Results The studies included 2′859 resections in patients aged 18 years and older who were hospitalized for abdominal cancer surgery between 2014 and 2018. Colon resections were the most common procedures (n = 1′690), followed by rectal resections (n = 709). For rectal, colon and pancreatic resections, an increase in the mean number of interventions per hospital and a reduction of low volume hospitals could be observed. For the relationship between hospital volume and outcomes, we did not observe a clear dose-response relationship, as no significantly better outcomes were observed in the higher-volume category than in the lower-volume category. Even though a positive “routine effect” cannot be excluded, our results suggest that even hospitals with low volumes are able to achieve comparable treatment outcomes to larger hospitals. Conclusion In summary, this study increases transparency on the relationship between hospital volume and treatment success. It shows that simple measures such as defining a minimum number of procedures only might not lead to the intended effects if other factors such as infrastructure, the operating team or aggregation level of the available data are not taken into account. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07513-5.
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12
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Rimini M, Casadei-Gardini A, Brandi G, Leone F, Fornaro L, Pella N, Silvestris N, Montagnani F, Lonardi S, Lai E, Galizia E, Santini D, Palloni A, Filippi R, Masi G, Aprile G, Aglietta M, Frega G, Fenocchio E, Vivaldi C, Satolli MA, Salani F, Scartozzi M, Faloppi L, Pellino A, Sperti E, Burgio V, Ratti F, Aldrighetti L, Cascinu S, Cucchetti A. Risk-adjusted analysis of survival variability among hospitals treating biliary malignancy. J Chemother 2022; 34:543-549. [PMID: 35156913 DOI: 10.1080/1120009x.2022.2036557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Biliary tract cancer's (BTC) treatment main stone for advanced stages is constituted by chemotherapy. Surgical centralization and physicians' confidence in the use of new technologies and molecular analysis turned out to be of interest and potentially influencing survival. After applying a random-effect model, the relationship between each clinical variable on the main outcome was investigated through multilevel mixed-effects logistic regression. The risk-standardized outcomes were calculated for each centre involved. In the unadjusted cohort the median survival was 8.6 months (95%C.I.: 7.8-9.3) with a 9-month survival rate of 48.3% (95%C.I.: 45.0-51.5). A substantial heterogeneity across hospitals was found (I2: 70.3%). In multilevel mixed effect logistic regression, male, being treated for gallbladder cancer, higher ECOG, increased NLR, CEA and Ca 19.9 and low value of haemoglobin showed to increase the odds for 9-month mortality. The model estimated that the residual variance observed in 9-month mortality was attributable for the 2.6% to the treating hospital. Through a multilevel mixed effect model, average risk-standardized mortality within 9 months was 50.1%. As noticeable, all hospital's risk-standardized mortality falls within 95%C.I., thus all participating centres provided similar outcomes when adjusted for patient case-mix. Heterogenicity between hospital did not affect the outcome in term of overall survival.
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Affiliation(s)
- Margherita Rimini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Brandi
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Leone
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Lorenzo Fornaro
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Nicola Silvestris
- Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Oncology, IRCCS Istituto Tumori "Giovanni Paolo II" of Bari, Bari, Italy
| | - Francesco Montagnani
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Sara Lonardi
- Oncology Unit 3, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Eleonora Lai
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Eva Galizia
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Daniele Santini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Andrea Palloni
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto Filippi
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gianluca Masi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Massimo Aglietta
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy
| | - Giorgio Frega
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
| | - Caterina Vivaldi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Maria Antonietta Satolli
- Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Salani
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Mario Scartozzi
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Luca Faloppi
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Antonio Pellino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.,Oncology Unit 1, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Elisa Sperti
- Division of Medical Oncology, Ordine Mauriziano Hospital, Torino, Italy
| | - Valentina Burgio
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | | | | | - Stefano Cascinu
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Oncology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
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13
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Akmaz B, van Kuijk SMJ, Sardari Nia P. Association between individual surgeon volume and outcome in mitral valve surgery: a systematic review. J Thorac Dis 2021; 13:4500-4510. [PMID: 34422376 PMCID: PMC8339780 DOI: 10.21037/jtd-21-578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/04/2021] [Indexed: 12/30/2022]
Abstract
Background Surgeon volume has been identified as a possible factor that influences outcomes in mitral valve (MV) surgery. The aim of this study was to systematically review all published studies on the association between individual surgeon volume and outcome in MV surgery. Methods PubMed was searched last on 19 November 2020. The reporting of this systematic review was done in accordance with PRISMA guidelines. Manuscripts were eligible when these studied individual surgeon volumes and its association with repair rate, mortality or reoperation. The methodological quality of the studies was assessed with the Newcastle-Ottawa Scale (NOS). Absolute numbers and percentages of the outcome measures, odds ratios (ORs), P values and threshold values regarding surgeon volume were collected. Results A total of 7 retrospective cohort studies were included in the qualitative analysis with total of 158488 patients. Definitions of surgeon volumes were found to be heterogenic and therefore pooling of data was not possible. Surgeon volume was significantly associated with repair rate (OR =1.25–5.5) and mortality (OR =0.46–0.84 and OR =1.50–2.27 depending on the reference group). Regarding reoperation, results were not consistent and did not always show a significant lower reoperation rate when surgeon volume increased. A mean threshold of minimally 30 MV surgeries per year was found. Discussion Higher surgeon volume is significantly associated with improved outcomes of repair rate and mortality. MV should preferentially be performed by high-volume surgeons and centralization of MV surgery might be necessary.
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Affiliation(s)
- Berdel Akmaz
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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14
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Christophersen C, Fonnes S, Baker JJ, Andresen K, Rosenberg J. Surgeon Volume and Risk of Reoperation after Laparoscopic Primary Ventral Hernia Repair: A Nationwide Register-Based Study. J Am Coll Surg 2021; 233:346-356.e4. [PMID: 34111532 DOI: 10.1016/j.jamcollsurg.2021.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Repairs of primary ventral hernias are common procedures but are associated with high recurrence rates. Therefore, it is important to investigate risk factors for recurrence to optimize current treatments. The aim of this study was to assess the impact of annual surgeon volume on the risk of reoperation for recurrence after primary ventral hernia repair. STUDY DESIGN We conducted a nationwide register-based study with data from the Danish Ventral Hernia Database and the Danish Patient Safety Authority's Online Register linked via surgeons' authorization identification. We included patients 18 years and older, undergoing umbilical or epigastric hernia repair between 2011 and 2020. Annual surgeon volume was categorized into ≤ 9, 10 to 19, 20 to 29, and ≥ 30 cases. Patients were followed until reoperation, death, emigration, or end of the study period. RESULTS We included 7,868 patients who underwent laparoscopic (n = 1,529 [19%]), open mesh (n = 4,138 [53%]), or open nonmesh (n = 2,201 [28%]) repair. There was an increased risk of reoperation after laparoscopic umbilical or epigastric hernia repair for surgeons with ≤ 9 (hazard ratio 6.57; p = 0.008), 10 to 19 (hazard ratio 6.58; p = 0.011), and 20 to 29 (hazard ratio 13.59; p = 0.001) compared with ≥ 30 cases/y. There were no differences in risk of reoperation after open mesh and open nonmesh repair in relation to annual surgeon volume. CONCLUSIONS There was a significantly higher risk of reoperation after laparoscopic primary ventral hernia repair performed by lower-volume surgeons compared with high-volume surgeons. Additional research investigating how sufficient surgical training and supervision are ensured is indicated to reduce risk of reoperation after primary ventral hernia repair.
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Affiliation(s)
- Camilla Christophersen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - Siv Fonnes
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Jason Joe Baker
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Kristoffer Andresen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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15
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MacDonald S, Johnson PM. Wide variation in surgical techniques to repair incisional hernias: a survey of practice patterns among general surgeons. BMC Surg 2021; 21:259. [PMID: 34030665 PMCID: PMC8145827 DOI: 10.1186/s12893-021-01261-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this research was to examine the self-reported practice patterns of Canadian general surgeons regarding the elective repair of incisional hernias. METHODS A mail survey was sent to all general surgeons in Canada. Data were collected regarding surgeon training, years in practice, practice setting and management of incisional hernias. Surgeons were asked to describe their usual surgical approach for a patient with a midline incisional hernia and a 10 × 6 cm fascial defect. RESULTS Of the 1876 surveys mailed out 555 (30%) were returned and 483 surgeons indicated that they perform incisional hernia repair. The majority (62%) have been in practice > 10 years and 73% regularly repair incisional hernias. In response to the clinical scenario of a patient with an incisional hernia, 74% indicated that they would perform an open repair and 18% would perform a laparoscopic repair. Ninety eight percent of surgeons would use mesh, 73% would perform primary fascial closure and 47% would perform a component separation. The most common locations for mesh placement were intraperitoneal (46%) and retrorectus/preperitoneal (48%). The most common repair, which was reported by 37% of surgeons, was an open operation, with mesh, with primary fascial closure and a component separation. CONCLUSIONS While almost all surgeons who perform incisional hernia repairs would use permanent mesh, there was substantial variation reported in surgical approach, mesh location, fascial closure and use of component separation techniques. It is unclear how this variability may impact healthcare resources and patient outcomes.
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Affiliation(s)
- Simon MacDonald
- Division of General Surgery, Dalhousie University, Halifax, NS, Canada
| | - Paul M Johnson
- Division of General Surgery, Dalhousie University, Halifax, NS, Canada. .,Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada. .,QEII Health Sciences Centre, Room 806 Victoria Building, VGH Site, 1276 South Park St., Halifax, NS, B3H 2Y9, Canada.
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16
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Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia 2020; 24:333-340. [PMID: 32152808 DOI: 10.1007/s10029-020-02150-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure. METHODS Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center. RESULTS Recommendations regarding patient selection, optimization and technique for TAR are presented. CONCLUSIONS While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.
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Affiliation(s)
- S J Zolin
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA.
| | - A Fafaj
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
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17
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Pereira JA, Bravo-Salva A, Montcusí B, Pérez-Farre S, Fresno de Prado L, López-Cano M. Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters. BMC Surg 2019; 19:103. [PMID: 31391112 PMCID: PMC6686257 DOI: 10.1186/s12893-019-0569-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia. METHODS We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared. RESULTS During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001). CONCLUSION Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.
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Affiliation(s)
- J A Pereira
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar. Hospital del Mar. P, Marítim 23-25, 08003, Barcelona, Spain. .,Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Dr. Aiguader 80, 08003, Barcelona, Spain.
| | - A Bravo-Salva
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar. Hospital del Mar. P, Marítim 23-25, 08003, Barcelona, Spain
| | - B Montcusí
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar. Hospital del Mar. P, Marítim 23-25, 08003, Barcelona, Spain
| | - S Pérez-Farre
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar. Hospital del Mar. P, Marítim 23-25, 08003, Barcelona, Spain
| | - L Fresno de Prado
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Dr. Aiguader 80, 08003, Barcelona, Spain
| | - M López-Cano
- Servicio de Cirugía General y Digestiva, Hospital Vall d'Hebrón, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain.,Departament de Cirurgia. Vall d'Hebrón, Universitat Autònoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
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18
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Johnston S, Lau C, Dargusch MS, Atrens A. Absorbable Mg surgical tack: Proof of concept &in situ fixation strength. J Mech Behav Biomed Mater 2019; 97:321-329. [PMID: 31153113 DOI: 10.1016/j.jmbbm.2019.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
Abstract
A prototype magnesium (Mg) surgical tack is tested comparatively against commercially available tacks made of titanium (ProTacktm, Medtronic) and PLGA (AbsorbaTacktm, Medtronic). The pull-out force is measured in situ in a lap-shear pull-out test, using porcine abdominal muscle tissue as a model. The Mg tack had a pull-out force comparable to those of the commercially available tacks. The majority of the Mg tacks also had a more ductile failure mode (i.e. the tacks deformed prior to failure), compared to the commercial tacks which pulled directly from the tissue with no deformation. The Mg tacks deformed as they were removed from the tissue, causing less damage to the tissue in the process. This is the first reported use of a Mg alloy in this application, and the proof of concept indicates that this is an area that deserves further interest and study.
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Affiliation(s)
- Sean Johnston
- The University of Queensland, Materials Engineering, School of Mechanical & Mining Engineering, Brisbane, Qld, 4072, Australia; The University of Queensland, Centre for Advanced Materials Processing and Manufacturing (AMPAM), Brisbane, Qld, 4072, Australia.
| | - Cora Lau
- The University of Queensland, Biological Resources, Brisbane, Qld, 4072, Australia
| | - Matthew S Dargusch
- The University of Queensland, Centre for Advanced Materials Processing and Manufacturing (AMPAM), Brisbane, Qld, 4072, Australia
| | - Andrej Atrens
- The University of Queensland, Materials Engineering, School of Mechanical & Mining Engineering, Brisbane, Qld, 4072, Australia
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19
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Surgeon factors are strongly correlated with who receives a sleeve gastrectomy versus a Roux-en-Y gastric bypass. Surg Obes Relat Dis 2019; 15:856-863. [DOI: 10.1016/j.soard.2019.03.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/20/2019] [Indexed: 12/27/2022]
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20
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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21
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Köckerling F. What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?-A Systematic Review. Front Surg 2018; 5:57. [PMID: 30324107 PMCID: PMC6172312 DOI: 10.3389/fsurg.2018.00057] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified. Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant. Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery. Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.
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Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
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22
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Sidhwa F, Itani KMF. Discussion: Fight or Flight: The Role of Staged Approaches to Complex Abdominal Wall Reconstruction. Plast Reconstr Surg 2018; 142:45S-46S. [PMID: 30138265 DOI: 10.1097/prs.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Feroze Sidhwa
- From the Department of Surgery, VA Boston Health Care System; and Harvard Medical School
| | - Kamal M F Itani
- From the Department of Surgery, VA Boston Health Care System; and Harvard Medical School
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Stabilini C, Cavallaro G, Bocchi P, Campanelli G, Carlucci M, Ceci F, Crovella F, Cuccurullo D, Fei L, Gianetta E, Gossetti F, Greco DP, Iorio O, Ipponi P, Marioni A, Merola G, Negro P, Palombo D, Bracale U. Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences. Int J Surg 2018; 54:222-235. [PMID: 29730074 DOI: 10.1016/j.ijsu.2018.04.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/06/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.
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Affiliation(s)
| | | | | | | | - Michele Carlucci
- Department of General and Emergency Surgery, IRCCS San Raffaele, Milan, Italy
| | - Francesca Ceci
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | | | - Diego Cuccurullo
- Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Landino Fei
- Department of Anaesthesiological, Surgical and Emergency Sciences, Second University of Naples, Italy
| | - Ezio Gianetta
- Department of Surgical Sciences, University of Genoa, Italy
| | | | | | - Olga Iorio
- General Surgery Unit, Aprilia Hospital, Aprilia (RM), Italy
| | - Pierluigi Ipponi
- General Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Giovanni Merola
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
| | - Paolo Negro
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Denise Palombo
- Department of Surgical Sciences, University of Genoa, Italy
| | - Umberto Bracale
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
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Murphy BL, Ubl DS, Zhang J, Habermann EB, Farley DR, Paley K. Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery 2018; 163:343-350. [DOI: 10.1016/j.surg.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/16/2017] [Accepted: 08/02/2017] [Indexed: 01/08/2023]
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Aquina CT, Fleming FJ, Becerra AZ, Hensley BJ, Noyes K, Monson JR, Temple LK, Cellini C. Who gets a pouch after colectomy in New York state and why? Surgery 2018; 163:305-310. [DOI: 10.1016/j.surg.2017.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
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Nimptsch U, Mansky T. Hospital volume and mortality for 25 types of inpatient treatment in German hospitals: observational study using complete national data from 2009 to 2014. BMJ Open 2017; 7:e016184. [PMID: 28882913 PMCID: PMC5589035 DOI: 10.1136/bmjopen-2017-016184] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To explore the existence and strength of a relationship between hospital volume and mortality, to estimate minimum volume thresholds and to assess the potential benefit of centralisation of services. DESIGN Observational population-based study using complete German hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)). SETTING All acute care hospitals in Germany. PARTICIPANTS All adult patients hospitalised for 1 out of 25 common or medically important types of inpatient treatment from 2009 to 2014. MAIN OUTCOME MEASURE Risk-adjusted inhospital mortality. RESULTS Lower inhospital mortality in association with higher hospital volume was observed in 20 out of the 25 studied types of treatment when volume was categorised in quintiles and persisted in 17 types of treatment when volume was analysed as a continuous variable. Such a relationship was found in some of the studied emergency conditions and low-risk procedures. It was more consistently present regarding complex surgical procedures. For example, about 22 000 patients receiving open repair of abdominal aortic aneurysm were analysed. In very high-volume hospitals, risk-adjusted mortality was 4.7% (95% CI 4.1 to 5.4) compared with 7.8% (7.1 to 8.7) in very low volume hospitals. Theminimum volume above which risk of death would fall below the average mortality was estimated as 18 cases per year. If all hospitals providing this service would perform at least 18 cases per year, one death among 104 (76 to 166) patients could potentially be prevented. CONCLUSIONS Based on complete national hospital discharge data, the results confirmed volume-outcome relationships for many complex surgical procedures, as well as for some emergency conditions and low-risk procedures. Following these findings, the study identified areas where centralisation would provide a benefit for patients undergoing the specific type of treatment in German hospitals and quantified the possible impact of centralisation efforts.
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Affiliation(s)
- Ulrike Nimptsch
- Department for Structural Advancement and Quality Management in Health Care, Technische Universitat Berlin, Berlin, Germany
| | - Thomas Mansky
- Department for Structural Advancement and Quality Management in Health Care, Technische Universitat Berlin, Berlin, Germany
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Aquina CT, Blumberg N, Becerra AZ, Boscoe FP, Schymura MJ, Noyes K, Monson JRT, Fleming FJ. Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection. Ann Surg 2017; 266:311-317. [PMID: 27631770 DOI: 10.1097/sla.0000000000001990] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery. BACKGROUND Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients. METHODS The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival. RESULTS Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival. CONCLUSIONS Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY ‡New York State Cancer Registry, New York State Department of Health, Albany, NY §Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida College of Medicine, Orlando, FL
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Antiporda M, Veenstra B, Jackson C, Kandel P, Daniel Smith C, Bowers SP. Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc 2017; 32:945-954. [PMID: 28733735 DOI: 10.1007/s00464-017-5770-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/14/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. METHODS We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7). RESULTS At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). CONCLUSIONS Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.
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Affiliation(s)
- Michael Antiporda
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Benjamin Veenstra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chloe Jackson
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Pujan Kandel
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Steven P Bowers
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Aquina CT, Becerra AZ, Probst CP, Xu Z, Hensley BJ, Iannuzzi JC, Noyes K, Monson JRT, Fleming FJ. Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team. Ann Surg 2017; 264:437-47. [PMID: 27433901 DOI: 10.1097/sla.0000000000001861] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions. SUMMARY BACKGROUND DATA Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies. METHODS Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions. RESULTS Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32). CONCLUSIONS This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
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Aquina CT, Fleming FJ, Becerra AZ, Xu Z, Hensley BJ, Noyes K, Monson JRT, Jusko TA. Explaining variation in ventral and inguinal hernia repair outcomes: A population-based analysis. Surgery 2017; 162:628-639. [PMID: 28528663 DOI: 10.1016/j.surg.2017.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/06/2017] [Accepted: 03/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair. METHODS The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003-2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence. RESULTS Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models. CONCLUSION The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Bradley J Hensley
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Katia Noyes
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
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Gossetti F, D'Amore L, Ceci F, Grimaldi MR, Negro P. Abdominal wall reconstruction (AWR): the need to identify the hospital units and referral centers entitled to perform it. Updates Surg 2017; 69:289-290. [PMID: 28378225 DOI: 10.1007/s13304-017-0428-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/23/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Francesco Gossetti
- Complex Operative Unit of Abdominal Wall Surgery, Department of General Surgery and Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Linda D'Amore
- Complex Operative Unit of Abdominal Wall Surgery, Department of General Surgery and Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesca Ceci
- Complex Operative Unit of Abdominal Wall Surgery, Department of General Surgery and Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Maria Romana Grimaldi
- Complex Operative Unit of Abdominal Wall Surgery, Department of General Surgery and Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Negro
- Complex Operative Unit of Abdominal Wall Surgery, Department of General Surgery and Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Köckerling F, Bittner R, Kraft B, Hukauf M, Kuthe A, Schug-Pass C. Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair? Surg Endosc 2017; 31:573-585. [PMID: 27334968 PMCID: PMC5266765 DOI: 10.1007/s00464-016-5001-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/23/2016] [Indexed: 01/23/2023]
Abstract
INTRODUCTION For open and endoscopic inguinal hernia surgery, it has been demonstrated that low-volume surgeons with fewer than 25 and 30 procedures, respectively, per year are associated with significantly more recurrences than high-volume surgeons with 25 and 30 or more procedures, respectively, per year. This paper now explores the relationship between the caseload and the outcome based on the data from the Herniamed Registry. PATIENTS AND METHODS The prospective data of patients in the Herniamed Registry were analyzed using the inclusion criteria minimum age of 16 years, male patient, primary unilateral inguinal hernia, TEP or TAPP techniques and availability of data on 1-year follow-up. In total, 16,290 patients were enrolled between September 1, 2009, and February 1, 2014. Of the participating surgeons, 466 (87.6 %) had carried out fewer than 25 endoscopic/laparoscopic operations (low-volume surgeons) and 66 (12.4 %) surgeons 25 or more operations (high-volume surgeons) per year. RESULTS Univariable (1.03 vs. 0.73 %; p = 0.047) and multivariable analysis [OR 1.494 (1.065-2.115); p = 0.023] revealed that low-volume surgeons had a significantly higher recurrence rate compared with the high-volume surgeons, although that difference was small. Multivariable analysis also showed that pain on exertion was negatively affected by a lower caseload <25 [OR 1.191 (1.062-1.337); p = 0.003]. While here, too, the difference was small, the fact that in that group there was a greater proportion of patients with small hernia defect sizes may have also played a role since the risk in that group was higher. In this analysis, no evidence was found that pain at rest [OR 1.052 (0.903-1.226); p = 0.516] or chronic pain requiring treatment [OR 1.108 (0.903-1.361); p = 0.326] were influenced by the surgeon volume. As confirmed by previously published studies, the data in the Herniamed Registry also demonstrated that the endoscopic/laparoscopic inguinal hernia surgery caseload impacted the outcome. However, given the overall high-quality level the differences between a "low-volume" surgeon and a "high-volume" surgeon were small. That was due to the use of a standardized technique, structured training as well as continuous supervision of trainees and surgeons with low annual caseload.
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Affiliation(s)
| | - R. Bittner
- Winghofer Medicum Hernia Center, Winghofer Straße 42, 72108 Rottenburg am Neckar, Germany
| | - B. Kraft
- Diakonie Hospital, Department of General and Visceral Surgery, Rosenbergstrasse 38, 70176 Stuttgart, Germany
| | - M. Hukauf
- StatConsult GmbH, Halberstädter Straße 40 a, 39112 Magdeburg, Germany
| | - A. Kuthe
- German Red Cross Hospital, Department of General and Visceral Surgery, Lützerodestraße 1, 30161 Hannover, Germany
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The impact of age on complications, survival, and cause of death following colon cancer surgery. Br J Cancer 2017; 116:389-397. [PMID: 28056465 PMCID: PMC5294480 DOI: 10.1038/bjc.2016.421] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/04/2016] [Accepted: 11/13/2016] [Indexed: 01/29/2023] Open
Abstract
Background: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. Methods: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I–III colon cancer resections (2004–2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65–74, ⩾75), complications, 1-year survival, and cause of death. Results: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65–74: HR=1.59, 95% CI=1.26–2.00; ⩾75: HR=2.57, 95% CI=2.09–3.16; sepsis: HR=2.58, 95% CI=2.13–3.11) and cardiovascular disease-specific death (65–74: HR=3.72, 95% CI=2.29–6.05; ⩾75: HR=7.02, 95% CI=4.44–11.10; sepsis: HR=2.33, 95% CI=1.81–2.99). Conclusions: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.
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Lorenz R, Stechemesser B, Reinpold W, Fortelny R, Mayer F, Schröder W, Köckerling F. Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School. Hernia 2016; 21:153-162. [PMID: 28032227 DOI: 10.1007/s10029-016-1566-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/17/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The increasingly more complex nature of hernia surgery means that training programs for young surgeons must now meet ever more stringent requirements. There is a growing demand for improved structuring and standardization of education and training in hernia surgery. MATERIALS AND METHODS In 2011, the concept of a Hernia School was developed in Germany and has been gradually implemented ever since. That concept comprises the following series of interrelated, tiered course elements: Hernie kompakt (Hernia compact), Hernie konkret (Hernia concrete), and Hernie complex (Hernia complex). All three course elements make provision for structured clinical training based on guest visits to approved hernia centers. The Hernia compact basic course imparts knowledge of anatomy working with fresh cadavers. Hernia surgery procedures can also be conducted using unfixed specimens. Knowledge of abdominal wall ultrasound diagnostics is also imparted and hernia surgery procedures simulated on pelvic trainers. In all three course elements, lectures are delivered by experts across the entire field of hernia surgery using evidence-based practices from the literature. RESULTS To date, eight Hernie kompakt (Hernia compact) courses have been conducted, in each case with up to 55 participants, and with a total of 390 participants. On evaluating the course, over 95% of participants expressed the view that the Hernia compact course content improved hernia surgery training. Following that positive feedback, the more advanced Hernie konkret (Hernia concrete) and Hernie complex (Hernia complex) course elements were introduced in 2016. CONCLUSION The experiences gained to date since the introduction of a Hernia School-a standardized curriculum concept for continuing training in hernia surgery-has been evaluated by participants as an improvement on hitherto hernia surgery training.
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Affiliation(s)
- R Lorenz
- 3 + Surgeons, Klosterstrasse 34/35, 13581, Berlin, Germany.
| | - B Stechemesser
- Hernia Center Cologne, PAN-Hospital, Zeppelinstrasse 1, 50667, Cologne, Germany
| | - W Reinpold
- Department of Surgery and Hernia Center, Wilhelmsburg Hospital Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - R Fortelny
- Department of General-, Visceral- and Oncologic Surgery, Wilhelminen Hospital, Montleartstrasse 37, 1160, Vienna, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - W Schröder
- Professional Association of German Surgeons, BDC-Academy, Langenbeck-Virchow-Haus, Luisenstraße 58/59, 10117, Berlin, Germany
| | - F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
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Aquina CT, Probst CP, Becerra AZ, Hensley BJ, Iannuzzi JC, Noyes K, Monson JR, Fleming FJ. The impact of surgeon volume on colostomy reversal outcomes after Hartmann's procedure for diverticulitis. Surgery 2016; 160:1309-1317. [DOI: 10.1016/j.surg.2016.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/20/2016] [Accepted: 05/11/2016] [Indexed: 12/22/2022]
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Loree JM, Javaheri KR, Lefresne SV, Speers CH, Ruan JY, Chang JT, Brown CJ, Kennecke HF, Olson RA, Cheung WY. Impact of Travel Distance and Urban-Rural Status on the Multidisciplinary Management of Rectal Cancer. J Rural Health 2016; 33:393-401. [PMID: 27717002 DOI: 10.1111/jrh.12219] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/08/2016] [Accepted: 08/29/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Optimal treatment of rectal cancer (RC) requires multidisciplinary care. We examined whether distance to treatment center or community size impacts access to multimodality care and population-based outcomes in RC. METHODS Patients diagnosed with stage II/III RC from 1999 to 2009 and treated at 1 of 6 regional cancer centers in British Columbia were reviewed. Distance to treatment center was determined for each patient. Communities were classified as rural, small, medium, and large population centers. Logistic and Cox regression models assessed associations of distance and community size with treatment received as well as cancer-specific (CSS) and overall survival (OS). RESULTS Of 3,158 patients, 93.6% underwent surgery, 86.3% received radiotherapy, and 51.3% were treated with adjuvant chemotherapy (AC). Median time from diagnosis to oncologic consultation was longer for those >100 km from a treatment center or residing in medium/rural communities. Logistic regression demonstrated no correlation between distance or community size and receipt of treatment modality. Univariate analysis showed similar CSS (P = .18, .88) and OS (P = .36, .47) based on community size and distance, respectively. In multivariate analysis, distance >100 km had inferior CSS (Hazard Ratio [HR] 1.39, 95% CI: 1.03-1.88; P = .031). There was no consistent trend between decreasing community size and outcomes; however, living in a small center was associated with improved OS (HR 0.58, 95% CI: 0.38-0.88; P = .011) and CSS (HR 0.42, 95% CI: 0.25-0.70; P = .001). CONCLUSIONS In this population-based study, there were no urban-rural differences in access to multidisciplinary care, but increased distance may be associated with worse cancer-specific outcomes.
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Affiliation(s)
- Jonathan M Loree
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Khodadad R Javaheri
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Shilo V Lefresne
- Division of Radiation Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline H Speers
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Jenny Y Ruan
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer T Chang
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carl J Brown
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Robert A Olson
- Division of Radiation Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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Xu Z, Mohile SG, Tejani MA, Becerra AZ, Probst CP, Aquina CT, Hensley BJ, Arsalanizadeh R, Noyes K, Monson JR, Fleming FJ. Poor compliance with adjuvant chemotherapy use associated with poorer survival in patients with rectal cancer: An NCDB analysis. Cancer 2016; 123:52-61. [DOI: 10.1002/cncr.30261] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/14/2016] [Accepted: 07/06/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Zhaomin Xu
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Supriya Gupta Mohile
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Mohamedtaki Abdulaziz Tejani
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Adan Z. Becerra
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Christian P. Probst
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | | | - Bradley J. Hensley
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Reza Arsalanizadeh
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Katia Noyes
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - John R.T. Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group; University of Central Florida College of Medicine; Orlando Florida
| | - Fergal J. Fleming
- Department of Surgery; University of Rochester Medical Center; Rochester New York
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Widmar M, Keskin M, Beltran P, Nash GM, Guillem JG, Temple LK, Paty PB, Weiser MR, Garcia-Aguilar J. Incisional hernias after laparoscopic and robotic right colectomy. Hernia 2016; 20:723-8. [PMID: 27469592 DOI: 10.1007/s10029-016-1518-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Incisional hernia (IH) is a common complication after colectomy, with impacts on both health care utilization and quality of life. The true incidence of IH after minimally invasive colectomy is not well described. The purpose of this study was to examine IH incidence after minimally invasive right colectomies (RC) and to compare the IH rates after laparoscopic (L-RC) and robotic (R-RC) colectomies. METHODS This is a retrospective review of patients undergoing minimally invasive RC at a single institution from 2009 to 2014. Only patients undergoing RC for colonic neoplasia were included. Patients with previous colectomy or intraperitoneal chemotherapy were excluded. Three L-RC patients were included for each R-RC patient. The primary outcome was IH rate based on clinical examination or computed tomography (CT). Univariate and multivariate time-to-event analyses were used to assess predictors of IH. RESULTS 276 patients where included, of which 69 had undergone R-RC and 207 L-RC. Patient and tumor characteristics were similar between the groups, except for higher tumor stage in L-RC patients. Both the median time to diagnosis (9.2 months) and the overall IH rate were similar between the groups (17.4 % for R-RC and 22.2 % for L-RC), as were all other postoperative complications. In multivariable analyses, the only significant predictor of IH was former or current tobacco use (hazard raio 3.0, p = 0.03). CONCLUSIONS This study suggests that the incidence of IH is high after minimally invasive colectomy and that this rate is equivalent after R-RC and L-RC. Reducing the IH rate represents an important opportunity for improving quality of life and reducing health care utilization after minimally invasive colectomy.
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Affiliation(s)
- M Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - M Keskin
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - P Beltran
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - G M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - J G Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - L K Temple
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - P B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - M R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - J Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Missed Opportunity. Ann Surg 2016; 264:127-34. [DOI: 10.1097/sla.0000000000001389] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
BACKGROUND Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects. OBJECTIVE The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications DESIGN This was a retrospective cohort study. SETTINGS The study included elective colorectal resections in New York State from 2001 to 2013. PATIENTS The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded. MAIN OUTCOME MEASURES Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured. RESULTS The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92-3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14-2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41-3.07)), and sepsis (OR = 4.51 (95% CI, 4.11-4.94)). LIMITATIONS Limitations include the retrospective design and the possibility of miscoding within administrative data. CONCLUSIONS Large surgeon- and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.
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Aquina CT, Probst CP, Becerra AZ, Hensley BJ, Iannuzzi JC, Noyes K, Monson JRT, Fleming FJ. High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection. Dis Colon Rectum 2016; 59:323-31. [PMID: 26953991 DOI: 10.1097/dcr.0000000000000539] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hospital-acquired Clostridium difficile infection is associated with adverse patient outcomes and high medical costs. The incidence and severity of C. difficile has been rising in both medical and surgical patients. OBJECTIVE Our aim was to assess risk factors and variation associated with the development of nosocomial C. difficile colitis among patients undergoing colorectal resection. DESIGN This was a retrospective cohort study. SETTINGS The study included segmental colectomy and proctectomy cases in New York State from 2005 to 2013. PATIENTS The study cohort included 150,878 colorectal resections. Patients with a documented previous history of C. difficile infection or residence outside of New York State were excluded. MAIN OUTCOME MEASURES A diagnosis of C. difficile colitis either during the index hospital stay or on readmission within 30 days was the main measure. RESULTS C. difficile colitis occurred in 3323 patients (2.2%). Unadjusted C. difficile colitis rates ranged from 0% to 11.3% among surgeons and 0% to 6.8% among hospitals. After controlling for patient, surgeon, and hospital characteristics using mixed-effects multivariable analysis, significant unexplained variation in C. difficile rates remained present across hospitals but not surgeons. Patient factors explained only 24% of the total hospital-level variation, and known surgeon and hospital-level characteristics explained an additional 8% of the total hospital-level variation. Therefore, ≈70% of the hospital variation in C. difficile infection rates remained unexplained by captured patient, surgeon, and hospital factors. Furthermore, there was an ≈5-fold difference in adjusted C. difficile rates across hospitals. LIMITATIONS A limited set of hospital and surgeon characteristics was available. CONCLUSIONS Colorectal surgery patients appear to be at high risk for C. difficile infection, and alarming variation in nosocomial C. difficile infection rates currently exists among hospitals after colorectal resection. Given the high morbidity and cost associated with C. difficile colitis, adopting institutional quality improvement programs and maintaining strict prevention strategies are of the utmost importance.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
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Abstract
BACKGROUND Current guidelines recommend extended-duration thromboprophylaxis for all abdominal oncologic resections. However, other high-risk patients may benefit from extended thromboprophylaxis. OBJECTIVE The purpose of this study was to identify risk factors for postdischarge venothromboembolism after colorectal procedures. DESIGN This was a retrospective cohort study. DATA SOURCES The New York Statewide Planning and Research Cooperative System database (2005-2013) was the data source for this study. STUDY SELECTION Colon and rectal resections were evaluated. Cases with in-hospital mortality or length of stay ≥30 days were excluded. MAIN OUTCOME MEASURES Postdischarge venothromboembolism was defined at 30-days after the procedure requiring representation to the emergency department or hospital admission with a new diagnosis of venothromboembolism using International Classification of Diseases, Ninth Revision, codes. Factors associated with postdischarge venothromboembolism were then evaluated using a hierarchical bivariate analysis. A hierarchical mixed-effects model was created using a manual stepwise approach assessing variables meeting p < 0.1 on bivariate analysis. RESULTS Among 128,163 patients, postdischarge venothromboembolism occurred in 0.7% (n = 789) of the population. Multiple factors were associated with postdischarge venothromboembolism on bivariate analysis. On multivariable analysis, benign conditions requiring operative intervention remained at high risk, with ulcerative colitis imparting an 93% increased odds when compared with other resections (OR, 1.93 (95% CI: 1.30-2.86); p = 0.001). Advanced malignancies (stages III and IV) were associated with increased postdischarge venothromboembolism risk, whereas stage I and II malignancies were not. The only protective factor was a laparoscopic procedure (OR, 0.80 (95% CI: 0.67-0.95); p = 0.010). There was no significant difference in procedure type after controlling for primary diagnosis. LIMITATIONS This was a retrospective analysis of administrative data with inherent limitations. Only patients who presented with postdischarge venothromboembolism to a hospital within New York State were captured. CONCLUSIONS This study identifies risk factors for postdischarge venothromboembolism and suggests that ulcerative colitis increases risk for postdischarge venothromboembolism whereas Crohn's disease does not. Ulcerative colitis postdischarge venothromboembolism rates exceeded even those of malignancy, suggesting that a future study is necessary to determine the efficacy of extended duration thromboprophylaxis in high-risk benign conditions, such as ulcerative colitis.
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Probst CP, Becerra AZ, Aquina CT, Tejani MA, Hensley BJ, González MG, Noyes K, Monson JRT, Fleming FJ. Watch and Wait?--Elevated Pretreatment CEA Is Associated with Decreased Pathological Complete Response in Rectal Cancer. J Gastrointest Surg 2016; 20:43-52; discussion 52. [PMID: 26546119 DOI: 10.1007/s11605-015-2987-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 10/10/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Between 10 and 30% of rectal cancer patients experience pathological complete response after neoadjuvant treatment. However, physiological factors predicting which patients will experience tumor response are largely unknown. Previous single-institution studies have suggested an association between elevated pretreatment carcinoembryonic antigen and decreased pathological complete response. METHODS Clinical stage II-III rectal cancer patients undergoing neoadjuvant chemoradiotherapy and surgical resection were selected from the 2006-2011 National Cancer Data Base. Multivariable analysis was used to examine the association between elevated pretreatment carcinoembryonic antigen and pathological complete response, pathological tumor regression, tumor downstaging, and overall survival. RESULTS Of the 18,113 patients meeting the inclusion criteria, 47% had elevated pretreatment carcinoembryonic antigen and 13% experienced pathological compete response. Elevated pretreatment carcinoembryonic antigen was independently associated with decreased pathological complete response (OR = 0.65, 95% CI = 0.52-0.77, p < 0.001), pathological tumor regression (OR = 0.74, 95% CI = 0.67-0.70, p < 0.001), tumor downstaging (OR = 0.77, 95% CI = 0.63-0.92, p < 0.001), and overall survival (HR = 1.45, 95% CI = 1.34-1.58, p < 0.001). CONCLUSION Rectal cancer patients with elevated pretreatment carcinoembryonic antigen are less likely to experience pathological complete response, pathological tumor regression, and tumor downstaging after neoadjuvant treatment and experience decreased survival. These patients may not be suitable candidates for an observational "watch-and-wait" strategy. Future prospective studies should investigate the relationships between CEA levels, neoadjuvant treatment response, recurrence, and survival.
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Affiliation(s)
- Christian P Probst
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA. .,Hematology/Oncology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Adan Z Becerra
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Mohamedtaki A Tejani
- Hematology/Oncology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bradley J Hensley
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Maynor G González
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Katia Noyes
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - John R T Monson
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Aquina CT, Blumberg N, Probst CP, Becerra AZ, Hensley BJ, Iannuzzi JC, Gonzalez MG, Deeb AP, Noyes K, Monson JRT, Fleming FJ. Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection. J Gastrointest Surg 2015; 19:1927-37. [PMID: 26264360 DOI: 10.1007/s11605-015-2903-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE Perioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications. METHODS The Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications. RESULTS Among 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94). CONCLUSION Significant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Christian P Probst
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Bradley J Hensley
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - James C Iannuzzi
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Maynor G Gonzalez
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Andrew-Paul Deeb
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Katia Noyes
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - John R T Monson
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Box SURG, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Aquina CT, Probst CP, Kelly KN, Iannuzzi JC, Noyes K, Fleming FJ, Monson JRT. The pitfalls of inguinal herniorrhaphy: Surgeon volume matters. Surgery 2015; 158:736-46. [PMID: 26036880 DOI: 10.1016/j.surg.2015.03.058] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/03/2015] [Accepted: 03/13/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is currently little information regarding the impact of procedure volume on outcomes after open inguinal hernia repair in the United States. Our hypothesis was that increasing procedure volume is associated with lesser rates of reoperation and resource use. METHODS The database of the Statewide Planning and Research Cooperative System was queried for elective open initial inguinal hernia repairs performed in New York State from 2001 to 2008 via the use of International Classification of Diseases, 9th Revision and Current Procedural Terminology codes. Surgeon and hospital procedure volumes were grouped into tertiles based on the number of open inguinal hernia repairs performed per year. Bivariate, hierarchical mixed effects Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total charges. RESULTS Among 151,322 patients who underwent open inguinal hernia repair, the overall rate of reoperation for recurrence within 5 years was 1.7% with a median time to reoperation of 1.9 years. An inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and health care costs (P < .001). After we controlled for surgeon, facility, operative and patient characteristics, low-volume surgeons (<25 repairs/year) had greater rates of reoperation (hazard ratio 1.23,95% confidence interval [95% CI] 1.11-1.36), longer procedure times (incidence rate ratio 1.22, 95% CI 1.21-1.24), and greater downstream costs (incidence rate ratio 1.13,95% CI 1.10-1.17) than high-volume surgeons (≥25 repairs/year). CONCLUSION Surgeon volume <25 cases per year for open inguinal hernia repair was independently associated with greater rates of reoperation for recurrence, worse operative efficiency, and greater health care costs. Referral to surgeons who perform ≥25 inguinal hernia repairs per year should be considered to decrease reoperation rates and resource use.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
| | - Christian P Probst
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
| | - Kristin N Kelly
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
| | - James C Iannuzzi
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
| | - Katia Noyes
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY
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