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Rumalla KC, Covell MM, Skandalakis GP, Rumalla K, Kassicieh AJ, Roy JM, Kazim SF, Segura A, Bowers CA. The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020). Spine J 2024; 24:582-589. [PMID: 38103740 DOI: 10.1016/j.spinee.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND CONTEXT Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSE This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTING Cross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLE The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURES CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODS Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTS There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSION Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.
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Affiliation(s)
- Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, 420 E Superior St., Chicago, IL, 60611, USA
| | - Michael M Covell
- School of Medicine, Georgetown University, 3900 Reservoir Road NW, Washington, DC, 20007, USA
| | - Georgios P Skandalakis
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Alexander J Kassicieh
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Joanna M Roy
- Topiwala National Medical College, Mumbai Central, Mumbai, Maharashtra 400008, India
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Aaron Segura
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 8342 S Levine Ln, Sandy, UT, 84070, USA.
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Abreu AA, Meier J, Alterio RE, Farah E, Bhat A, Wang SC, Porembka MR, Mansour JC, Yopp AC, Zeh HJ, Polanco PM. Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States. HPB (Oxford) 2024; 26:212-223. [PMID: 37863740 DOI: 10.1016/j.hpb.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/12/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.
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Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Fukada M, Murase K, Higashi T, Yasufuku I, Sato Y, Tajima JY, Kiyama S, Tanaka Y, Okumura N, Matsuhashi N. Perioperative predictive factors of failure to rescue following highly advanced hepatobiliary-pancreatic surgery: a single-institution retrospective study. World J Surg Oncol 2023; 21:365. [PMID: 37996865 PMCID: PMC10668400 DOI: 10.1186/s12957-023-03257-6] [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: 06/14/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Failure to rescue (FTR), defined as a postoperative complication leading to death, is a recently described outcome metric used to evaluate treatment quality. However, the predictive factors for FTR, particularly following highly advanced hepatobiliary-pancreatic surgery (HBPS), have not been adequately investigated. This study aimed to identify perioperative predictive factors for FTR following highly advanced HBPS. METHODS This single-institution retrospective study involved 177 patients at Gifu University Hospital, Japan, who developed severe postoperative complications (Clavien-Dindo classification grades ≥ III) between 2010 and 2022 following highly advanced HBPS. Univariate analysis was used to identify pre-, intra-, and postoperative risks of FTR. RESULTS Nine postoperative mortalities occurred during the study period (overall mortality rate, 1.3% [9/686]; FTR rate, 5.1% [9/177]). Univariate analysis indicated that comorbid liver disease, intraoperative blood loss, intraoperative blood transfusion, postoperative liver failure, postoperative respiratory failure, and postoperative bleeding significantly correlated with FTR. CONCLUSIONS FTR was found to be associated with perioperative factors. Well-coordinated surgical procedures to avoid intra- and postoperative bleeding and unnecessary blood transfusions, as well as postoperative team management with attention to the occurrence of organ failure, may decrease FTR rates.
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Affiliation(s)
- Masahiro Fukada
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Katsutoshi Murase
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Toshiya Higashi
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Itaru Yasufuku
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Yuta Sato
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Jesse Yu Tajima
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Shigeru Kiyama
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Yoshihiro Tanaka
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Naoki Okumura
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Nobuhisa Matsuhashi
- Department of Gastroenterological Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan.
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Divakaran P, Hong JS, Abbas S, Gwini SM, Nagra S, Stupart D, Guest G, Watters D. Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience. World J Surg 2023; 47:2145-2153. [PMID: 37225931 PMCID: PMC10208200 DOI: 10.1007/s00268-023-07061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery. METHODS A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication. CONCLUSION Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.
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Affiliation(s)
- Pranav Divakaran
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia.
| | - Joshua Sungho Hong
- Warrnambool Base Hospital, Southwest Healthcare, 25 Ryot Street, Warrnambool, VIC, 3280, Australia
| | - Saleh Abbas
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Stella-May Gwini
- Biostatistics Support Service, Level 2 Kitchner House, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
| | - Sonalmeet Nagra
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Douglas Stupart
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Glenn Guest
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - David Watters
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
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Hirano Y, Kaneko H, Konishi T, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Itano O, Yasunaga H, Kitagawa Y. Impact of Body Mass Index on Major Complications, Multiple Complications, In-hospital Mortality, and Failure to Rescue After Esophagectomy for Esophageal Cancer: A Nationwide Inpatient Database Study in Japan. Ann Surg 2023; 277:e785-e792. [PMID: 35129484 DOI: 10.1097/sla.0000000000005321] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association of BMI with mortality and related outcomes after oncologic esophagectomy. SUMMARY BACKGROUND DATA Previous studies showed that high BMI was a risk factor for anastomotic leakage and low BMI was a risk factor for respiratory complications after esophagectomy. However, the association between BMI and in-hospital mortality after oncologic esophagectomy remains unclear. METHODS Data for patients who underwent esophagectomy for esophageal cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Multivariate regression analyses and restricted cubic spline analyses were used to investigate the associations between BMI and short-term outcomes, adjusting for potential confounders. RESULTS Among 39,406 eligible patients, in-hospital mortality, major complications, and multiple complications (≥2 major complications) occurred in 1069 (2.7%), 14,824 (37.6%), and 3621 (9.2%), respectively. Compared with normal weight (18.5-22.9 kg/m 2 ), severe underweight (<16.0 kg/m 2 ), mild/moderate underweight (16.0-18.4 kg/m 2 ), and obese (≥27.5 kg/m 2 )were significantly associated with higher in-hospital mortality [odds ratio 2.20 (95% confidence interval 1.65-2.94), 1.25 (1.01-1.49), and 1.48 (1.05-2.09), respectively]. BMI showed U-shaped dose-response associations with mortality, major complications, and multiple complications. BMI also showed a reverse J-shaped association with failure to rescue (death after major complications). CONCLUSIONS Both high BMI and low BMI were associated with mortality, major complications and multiple complications after esophagectomy for esophageal cancer. Patients with low BMI were more likely to die once a major complication occurred. The present results can assist with risk stratification in patients undergoing oncologic esophagectomy.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Hidehiro Kaneko
- Department of cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Gazivoda VP, Greenbaum A, Beier MA, Davis CH, Kangas-Dick AW, Langan RC, Grandhi MS, August DA, Alexander HR, Pitt HA, Kennedy TJ. Pancreatoduodenectomy: the Metabolic Syndrome is Associated with Preventable Morbidity and Mortality. J Gastrointest Surg 2022; 26:2167-2175. [PMID: 35768718 DOI: 10.1007/s11605-022-05386-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with metabolic syndrome (MS) may have increased perioperative morbidity and mortality. The aim of this analysis was to investigate the association of MS with mortality, serious morbidity, and pancreatectomy-specific outcomes in patients undergoing pancreatoduodenectomy (PD). METHODS Patients with MS who underwent PD were selected from the 2014-2018 ACS-NSQIP pancreatectomy-specific database. MS was defined as obesity (BMI ≥ 30 kg/m2), diabetes, and hypertension. Demographics and outcomes were compared by χ2 and Mann-Whitney tests, and adjusted odds ratios from multivariable logistic regression assessed the association between MS and primary outcomes. RESULTS Of 19,054 patients who underwent PD, 7.3% (n = 1388) had MS. On univariable analysis, patients with MS had significantly worse outcomes (p < 0.05): 30-day mortality (3% vs 1.8%), serious morbidity (26% vs 23%), re-intubation (4.9% vs 3.5%), pulmonary embolism (2.0% vs 1.1%), acute renal failure (1.5% vs 0.9%), cardiac arrest (1.9% vs 1.0%), and delayed gastric emptying (18% vs 16.5%). On multivariable analysis, 30-day mortality was significantly increased in patients with MS (aOR: 1.53, p < 0.01). CONCLUSION Metabolic syndrome is associated with increased morbidity and mortality in patients undergoing pancreatoduodenectomy. The association with mortality is a novel observation. Perioperative strategies aimed at reduction and/or mitigation of cardiac, pulmonary, thrombotic, and renal complications should be employed in this population given their increased risk.
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Affiliation(s)
- Victor P Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Alissa Greenbaum
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Matthew A Beier
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ, 08901, USA
| | - Catherine H Davis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Aaron W Kangas-Dick
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Russell C Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Miral S Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - H Richard Alexander
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Henry A Pitt
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Timothy J Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA.
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Ignatavicius P, Oberkofler CE, Jonas JP, Mullhaupt B, Clavien PA. The essential requirements for an HPB centre to deliver high-quality outcomes. J Hepatol 2022; 77:837-848. [PMID: 35577030 DOI: 10.1016/j.jhep.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022]
Abstract
The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.
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Affiliation(s)
- Povilas Ignatavicius
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan Philipp Jonas
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Beat Mullhaupt
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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8
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Abstract
Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR-the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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Affiliation(s)
- Elizabeth M Gleeson
- University of Edinburgh and Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland UK.
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey and Robert Wood Johnson University Hospital, 195 Little Albany Street, ET 834, New Brunswick, NJ 09083, USA
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9
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Giuliani T, Marchegiani G, Di Gioia A, Amadori B, Perri G, Salvia R, Bassi C. Patterns of mortality after pancreatoduodenectomy: A root cause, day-to-day analysis. Surgery 2022; 172:329-335. [PMID: 35216825 DOI: 10.1016/j.surg.2022.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/24/2021] [Accepted: 01/11/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mortality is consistently reported as an outcome metric in pancreatic surgery. Given its heterogeneity, better characterization of it might provide crucial insights for clinical practice. This study aimed to analyze the timeline and sequence of events that lead to death after pancreatoduodenectomy to identify possible distinct pathways of mortality. METHODS All consecutive pancreatoduodenectomy cases from 2010 to 2020 were retrospectively analyzed. A day-to-day appraisal of the postoperative course of each fatality was performed and visualized graphically. The graphical analysis allowed for pattern identification. The respective predictors were explored through logistic regression. RESULTS Out of 2065 pancreatoduodenectomy patients, in-hospital mortality was 3.1%. With graphical analysis, 3 patterns were identified. Pattern A deaths (71.4%, n = 45) occurred after a median of 43 days (14-260), following pancreas-specific complications such as postoperative pancreatic fistula, postpancreatectomy hemorrhage, and delayed gastric emptying. Pattern B deaths (15.9%, n = 10) occurred after a median of 18 days (1-55), succeeding a critical status in the early postoperative course, mainly related to elevated surgical complexity. Patients with pattern C (12.7%) died after a median of 8 days, mostly for unknown cause after an uneventful postoperative course. The predictors of each pattern were distinctive. CONCLUSION Mortality after pancreatoduodenectomy occurs through 3 distinct pathways. This knowledge could spawn an additional endpoint of value to clinicians and hospitals, delivering a supplementary tool for comparison between centers and diversified patient populations, and it might facilitate the identification of the best targets for improvement. Further studies are needed to validate this tripartite reclassification.
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Affiliation(s)
- Tommaso Giuliani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy.
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
| | - Beatrice Amadori
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Italy
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10
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Benzing C, Schmelzle M, Atik CF, Krenzien F, Mieg A, Haiden LM, Wolfsberger A, Schöning W, Fehrenbach U, Pratschke J. Factors associated with failure to rescue after major hepatectomy for perihilar cholangiocarcinoma: A 15-year single-center experience. Surgery 2022; 171:859-866. [DOI: 10.1016/j.surg.2021.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/20/2022]
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Li V, Serrano PE. Prediction of Postoperative Mortality in Patients With Organ Failure Following Pancreaticoduodenectomy. Am Surg 2021:31348211065104. [PMID: 34955034 DOI: 10.1177/00031348211065104] [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: 11/15/2022]
Abstract
BACKGROUND Failure to rescue (FTR) patients with postoperative complications contribute to a significant proportion of postoperative mortality. Our main objective was to determine the risk factors for FTR among patients undergoing pancreaticoduodenectomy who suffered a life-threatening complication requiring intensive care unit (ICU) management. MATERIALS AND METHODS Consecutive patients undergoing pancreaticoduodenectomy from 2011 to 2020 were reviewed retrospectively. Causes of organ failure were described as the one that most commonly contributed to patient's transfer to ICU or death. Two groups were created based on whether patients had FTR and risk factors for FTR were compared. The impact of baseline characteristics, operative characteristics, and risk scoring on FTR was analyzed using multiple logistic regression. RESULTS There were 19/58 (33%) FTR patients. Baseline, operative characteristics, postoperative complications, and length of hospital and ICU stay were similar between groups. However, a higher proportion of FTR patients experienced a postoperative pancreatic fistula (POPF) (16% vs 2.6%, P = .062). Among patients who experienced a POPF, the FTR group had a trend in delayed time from diagnosis to treatment (7 vs 23 hours, P=.131). Renal complications (OR 6.12, 95% CI, 1.23 to 38.43, P = .035) and time from POPF diagnosis to treatment (OR 1.05, 95% CI, 1.00 to 1.11, P = .036) were independent predictors of FTR by multivariable analysis. CONCLUSION The occurrence of certain postoperative complications such as renal complications as well as delayed timing of the management of POPF is predictive of FTR following pancreaticoduodenectomy, especially as delayed timing to treatment is a risk factor for FTR.
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Affiliation(s)
- Vivian Li
- Division of General Surgery, Department of Surgery, 3710McMaster University, Hamilton, ON, Canada
| | - Pablo E Serrano
- Division of General Surgery, Department of Surgery, 3710McMaster University, Hamilton, ON, Canada
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12
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Rosero EB, Romito BT, Joshi GP. Failure to rescue: A quality indicator for postoperative care. Best Pract Res Clin Anaesthesiol 2021; 35:575-589. [PMID: 34801219 DOI: 10.1016/j.bpa.2020.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 11/24/2022]
Abstract
Postoperative complications occur despite optimal perioperative care and are an important driver of mortality after surgery. Failure to rescue, defined as death in a patient who has experienced serious complications, has emerged as a quality metric that provides a mechanistic pathway to explain disparities in mortality rates among hospitals that have similar perioperative complication rates. The risk of failure to rescue is higher after invasive surgical procedures and varies according to the type of postoperative complication. Multiple patient factors have been associated with failure to rescue. However, failure to rescue is more strongly correlated with hospital factors. In addition, microsystem factors, such as institutional safety culture, teamwork, and other attitudes and behaviors may interact with the hospital resources to effectively prevent patient deterioration. Early recognition through bedside and remote monitoring is the first step toward prevention of failure to rescue followed by rapid response initiatives and timely escalation of care.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Abstract
OBJECTIVE This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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14
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Latenstein AEJ, Mackay TM, Beane JD, Busch OR, van Dieren S, Gleeson EM, Koerkamp BG, van Santvoort HC, Wellner UF, Williamsson C, Tingstedt B, Keck T, Pitt HA, Besselink MG. The use and clinical outcome of total pancreatectomy in the United States, Germany, the Netherlands, and Sweden. Surgery 2021; 170:563-570. [PMID: 33741182 DOI: 10.1016/j.surg.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/16/2021] [Accepted: 02/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries. METHODS Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014-2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo ≥3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume ≥40 pancreatoduodenectomies annually; data available for the Netherlands and Germany). RESULTS In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age ≥75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P = .002), but not in Germany (9.8% vs 10.6%; P = .733). CONCLUSION Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/anouklatenstein
| | - Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/tarammackay
| | - Joal D Beane
- Department of Surgical Oncology, Ohio State University, Columbus, OH
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Tobias Keck
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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15
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Mpody C, Arends J, Aldrink JH, Olutoye OO, Tobias JD, Nafiu OO. Prognostic profiling of children with serious post-operative complications: A novel probability model for failure to rescue. J Pediatr Surg 2021; 56:207-212. [PMID: 33127062 DOI: 10.1016/j.jpedsurg.2020.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications. METHODS We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012-2017). We evaluated the rate of FTR according to pre-operative comorbidity burden. RESULTS We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%-0.2%) among low-risk cases, 3.3%(95%CI:3.0%-3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%-24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days). CONCLUSION We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jordan Arends
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
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16
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Peacock O, Yanni F, Kuryba A, Cromwell D, Lockwood S, Anderson I, Vohra RS. Failure to rescue patients after emergency laparotomy for large bowel perforation: analysis of the National Emergency Laparotomy Audit (NELA). BJS Open 2021; 5:zraa060. [PMID: 33609399 PMCID: PMC7896807 DOI: 10.1093/bjsopen/zraa060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/01/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability. METHODS Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality. RESULTS Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770). CONCLUSION Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.
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Affiliation(s)
- O Peacock
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Yanni
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - I Anderson
- University of Manchester School of Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - R S Vohra
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
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17
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Roussas A, Masjedi A, Hanna K, Zeeshan M, Kulvatunyou N, Gries L, Tang A, Joseph B. Number and Type of Complications Associated With Failure to Rescue in Trauma Patients. J Surg Res 2020; 254:41-48. [PMID: 32408029 DOI: 10.1016/j.jss.2020.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/28/2020] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma. METHODS We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR. RESULTS A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications. CONCLUSIONS Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Adam Roussas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Aaron Masjedi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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18
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Welch JC, Gleeson EM, Karachristos A, Pitt HA. Hepatopancreatoduodenectomy in North America: are the outcomes acceptable? HPB (Oxford) 2020; 22:360-367. [PMID: 31519357 DOI: 10.1016/j.hpb.2019.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatopancreatoduodenectomies (HPD) are historically associated with high morbidity and mortality. Currently, no data with hepatopancreatobiliary-specific complications have been available for HPD in North America. The aim of this retrospective analysis was to compare the outcomes of HPD to those of major hepatectomy (MH) and pancreatoduodenectomy (PD) in North America. METHODS The 2014-16 American College of Surgeons-National Surgical Quality Improvement Program database was queried for MH, PD, and HPD. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to match 23 HPDs to 92 MHs and 138 PDs by 28 demographic, comorbidity, laboratory, operative and pathologic variables. Outcomes were compared among these three groups. RESULTS The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p < 0.01) compared to both MH (51%, 7.6%) and PD (52%, 1.4%). Post-hepatectomy liver failure (PHLF) was more common (p < 0.01) in HPD patients, but pancreatic fistula rates were similar. CONCLUSION The morbidity and mortality after HPD are significantly higher than after MH or PD alone and may explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.
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Affiliation(s)
- Jonathan C Welch
- Lewis Katz School of Medicine at Temple University, 3500 N. Broad St., Philadelphia, PA, 19140, USA
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA
| | - Andreas Karachristos
- Department of Surgery, University of South Florida, 2 Tampa General Circle 7th Floor, Tampa, FL, 33606, USA
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, 3509 N. Broad St., Boyer Pavilion, E938, Philadelphia, PA 1914, USA.
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