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Vogel PA. Der erfahrene Chirurg als unabhängiger Risikofaktor für die Morbidität nach Cholezystektomie. Eine multivariate Analyse von 710 Patienten. Zentralbl Chir 2022; 147:42-53. [DOI: 10.1055/a-1712-4749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Zusammenfassung
Einleitung Bei komplexeren chirurgischen Eingriffen wie der Kolonresektion, herzchirurgischen Eingriffen, arteriellen Rekonstruktionen oder Leberresektionen ist der Einfluss des
Chirurgen auf die postoperative Morbidität nachgewiesen. Bei Routineeingriffen wie der Cholezystektomie liegen bislang keine Erkenntnisse zum Zusammenhang von Operateur und Morbidität vor.
Insbesondere Untersuchungen bei erfahrenen Chirurgen fehlen.
Methoden Es wurden 710 konsekutive Patienten, die zwischen Januar 2014 und Dezember 2018 von erfahrenen Chirurgen (über n = 300 Cholezystektomien vor Beginn der Untersuchung, über 5
Jahre nach bestandener Facharztprüfung) cholezystektomiert wurden, untersucht. In einer univariaten Analyse wurde der Einfluss von Patientenmerkmalen, Laborparametern, chirurgischen
Parametern und des Operateurs auf die postoperative Morbidität analysiert. Die Variablen mit statistischer Signifikanzen wurden dann einer multivariaten logistischen Regressionsanalyse
unterzogen.
Ergebnisse Die Mortalität lag bei 5 von 710 (0,7%), die Morbidität bei 58 von 710 (8,2%). 37 von 710 Patienten erlitten eine chirurgische Komplikation, 21 von 710 Patienten eine
nicht chirurgische Komplikation. Hinsichtlich der Gesamtmorbidität waren in multivariater Analyse der Kreatininwert (OR 1,29; KI 1,01–1,648; p = 0,042), GOT (OR 1,0405; KI 1–1,01; p = 0,03),
offene und Konversions-Cholezystektomie (OR 4,134; KI 1,587–10,768; p = 0,004) und der individuelle Chirurg (OR bis 40,675; p = 0,001) ein unabhängiger Risikofaktor. Bei Analyse der
chirurgischen Komplikationen blieben offene und Konversions-Cholezystektomie (OR 8,104; KI 3,03–21,68; p < 0,001) sowie der individuelle Chirurg (OR bis 79,69; p = 0,005) ein statistisch
signifikanter unabhängiger Risikofaktor.
Schlussfolgerung Der individuelle Chirurg ist auch bei einem Routineeingriff wie der Cholezystektomie ein unabhängiger Risikofaktor für die Morbidität. Dies gilt auch für erfahrene
Chirurgen mit Facharztstatus und hoher Caseload. Im Hinblick auf die Patientensicherheit und Verbesserungen der Ergebnisqualität muss daher diskutiert werden, ob eine routinemäßige
risikoadjustierte Messung der individuellen Ergebnisse eines jeden Chirurgen als Basis eines gezielten Qualifizierungprogramms sinnvoll ist.
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Affiliation(s)
- Peter Alexander Vogel
- Allgemein-, Viszeral- und Minimalinvasive Chirurgie, Klinikum Bad Hersfeld GmbH, Bad Hersfeld, Deutschland
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Hospital Safety-Net Burden Is Associated With Increased Inpatient Mortality and Perioperative Complications After Colectomy. J Surg Res 2021; 259:24-33. [DOI: 10.1016/j.jss.2020.11.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/19/2020] [Accepted: 11/01/2020] [Indexed: 12/14/2022]
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Paredes AZ, Hyer JM, Tsilimigras DI, Pawlik TM. Hepatopancreatic Surgery in the Rural United States: Variation in Outcomes at Critical Access Hospitals. J Surg Res 2021; 261:123-129. [PMID: 33422902 DOI: 10.1016/j.jss.2020.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/03/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. MATERIALS AND METHODS Medicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). RESULTS Patients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). CONCLUSIONS Only a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Burns EM, Poulton T, Deputy M, Pinkney T, Guy R. An audit of process and outcome for emergency colectomy in England and Wales. Colorectal Dis 2020; 22:2133-2139. [PMID: 32936991 DOI: 10.1111/codi.15367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/22/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022]
Abstract
AIM The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. METHOD The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65 years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. RESULTS In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5 days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10 days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age > 55 years [OR 3.59 (1.05-12.21), P = 0.041], female gender [OR 2.88 (1.27-6.52), P = 0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P = 0.007] were associated with increased mortality. CONCLUSION There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.
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Affiliation(s)
- E M Burns
- St Mark's Hospital and Academic Institute, London, UK.,Department of Cancer and Surgery, Imperial College London, London, UK
| | - T Poulton
- Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK
| | - M Deputy
- St Mark's Hospital and Academic Institute, London, UK.,Department of Cancer and Surgery, Imperial College London, London, UK
| | - T Pinkney
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - R Guy
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
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Dreifuss NH, Schlottmann F, Bun ME, Rotholtz NA. Emergent laparoscopic sigmoid resection for perforated diverticulitis: can it be safely performed by residents? Colorectal Dis 2020; 22:952-958. [PMID: 31955484 DOI: 10.1111/codi.14973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
AIM Outcomes after resident involvement in emergent colectomies have rarely been studied. The aim of this study was to analyse the outcomes of laparoscopic sigmoidectomy for Hinchey III diverticulitis performed by residents. METHOD This study was a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for diverticulitis. The sample was divided into two groups: patients operated on by a supervised resident (SR) or a senior surgeon (SS). Supervising surgeons and SSs could be general surgeons (GSs) or colorectal surgeons (CSs). A SR was considered the first surgeon if he/she completed at least three of five defined steps of the procedure. The primary end-points included length of hospital stay (LOS), morbidity and 30-day mortality. A sub-analysis of patients operated on by a SR assisted by either a CS or GS was performed. RESULTS Supervised residents and SSs operated on 59 and 42 patients, respectively. The presence of a CS was more frequent in the SS group (SR 41% vs SS 81%, P < 0.001). LOS (SR 9.4 days vs SS 6.4 days, P = 0.04) was higher in the SR group. Overall morbidity (SR 39% vs SS 43%, P = 0.69) and 30-day mortality (SR 5% vs SS 5%, P = 0.94) were also comparable among the groups. Procedures performed by SRs and supervised by a CS were associated with lower morbidity (GS 48% vs CS 25%, P = 0.06) and mortality (GS 8% vs CS 0%, P = 0.26). CONCLUSION Laparoscopic sigmoidectomy for Hinchey III diverticulitis has comparable outcomes when performed by a supervised SR or a SS. Procedures performed by residents assisted by a CS seem to have better outcomes than those assisted by a GS.
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Affiliation(s)
- N H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - M E Bun
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.,Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - N A Rotholtz
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.,Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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Abstract
BACKGROUND Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN This was a retrospective cohort study. SETTINGS Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.
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Haines K, Rust C, Nguyen BP, Agarwal S. Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status. Am Surg 2018. [DOI: 10.1177/000313481808401230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Clayton Rust
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Pham Nguyen
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Smith SA, Yamamoto JM, Roberts DJ, Tang KL, Ronksley PE, Dixon E, Buie WD, James MT. Weekend Surgical Care and Postoperative Mortality: A Systematic Review and Meta-Analysis of Cohort Studies. Med Care 2018; 56:121-129. [PMID: 29251716 PMCID: PMC5770102 DOI: 10.1097/mlr.0000000000000860] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An association between weekend health care delivery and poor outcomes has become known as the "weekend effect." Evidence for such an association among surgery patients has not previously been synthesized. OBJECTIVE To systematically review associations between weekend surgical care and postoperative mortality. METHODS We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models. RESULTS Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97-1.11); Wednesday OR=1.08 (95% CI=0.98-1.19); Thursday OR=1.12 (95% CI=1.03-1.22); Friday OR=1.24 (95% CI=1.10-1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08-1.49). CONCLUSIONS Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.
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Affiliation(s)
| | | | | | | | | | | | | | - Matthew T. James
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Lieberman-Cribbin W, Galsky M, Casey M, Liu B, Oh W, Flores R, Taioli E. Hospital Centralization Impacts High-Risk Lung and Bladder Cancer Surgical Patients. Cancer Invest 2017; 35:652-661. [DOI: 10.1080/07357907.2017.1406495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Wil Lieberman-Cribbin
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Galsky
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin Casey
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bian Liu
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Oh
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raja Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hoehn RS, Hanseman DJ, Dhar VK, Go DE, Edwards MJ, Shah SA. Opportunities to Improve Care of Hepatocellular Carcinoma in Vulnerable Patient Populations. J Am Coll Surg 2017; 224:697-704. [DOI: 10.1016/j.jamcollsurg.2016.12.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
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