Adrenalectomy in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study

Two Decades' Outcomes and Trends of Adrenalectomy for Benign Pathologies in Veterans

BACKGROUND

Since the introduction of laparoscopic adrenalectomy (LA) in 1992, it has become the standard of care for most adrenal benign pathologies. This study compares the outcomes and trends of open (OA) versus LA in veterans for benign pathologies.

METHODS

Veterans Affairs Surgical Quality Improvement Program was queried for adrenalectomies performed for benign pathologies during the period 2000-2019. Data collection included demographics, comorbidities, operative details, and postoperative outcomes.

RESULTS

A total of 1683 patients were included (91.4% males, mean age 59.6, mean body mass index 31.2, and 87.2% with American Society of Anesthesiologists class≥III). Overall, the mean operative time (OT) was 3.2 hours, the majority performed by general surgeons (71.4%), and the mean length of stay (LOS) was 4.1 days. There were 12 (0.7%) 30-day mortalities, and 162 patients (8.8%) developed ≥1 complication. LA was performed in 70.9% (1306), with the conversion rate of 0.85% (10). When compared with OA, patients with the laparoscopic approach were functionally independent, shorter OT, less intraoperative blood transfusion, shorter LOS, and lower mortality and morbidity. Dependent functional status, congestive heart failure, American Society of Anesthesiologists class ≥III, and smoking were independent predictors of mortality, whereas intraoperative transfusions, chronic obstructive pulmonary disease, and dependent functional status were predictors of morbidity. Trend analysis showed an 8-fold increase in the use of LA. However, trend analysis for morbidity and mortality rates showed no significant change for both approaches.

CONCLUSION

LA is being well adopted in the veterans affairs system with an 8-fold increase over 20 years, with lower morbidity and mortality compared with the open approach for benign adrenal pathologies.

Predictors of complication after adrenalectomy

Purpose:

To investigate risk factors for complications in patients undergoing adrenalectomy.

Materials and Methods:

A retrospective search of our institutional database was performed of patients who underwent adrenalectomy, between 2014 and 2018. Clinical parameters and adrenal disorder characteristics were assessed and correlated to intra and post-operative course. Complications were analyzed within 30-days after surgery. A logistic regression was performed in order to identify independent predictors of morbidity in patients after adrenalectomy.

Results:

The files of 154 patients were reviewed. Median age and Body Mass Index (BMI) were 52-years and 27.8kg/m², respectively. Mean tumor size was 4.9±4cm. Median surgery duration and estimated blood loss were 140min and 50mL, respectively. There were six conversions to open surgery. Minor and major post-operative complications occurred in 17.5% and 8.4% of the patients. Intra-operative complications occurred in 26.6% of the patients. Four patients died. Mean hospitalization duration was 4-days (Interquartile Range: 3-8). Patients age (p=0.004), comorbidities (p=0.003) and pathological diagnosis (p=0.003) were independent predictors of post-operative complications. Tumor size (p<0.001) and BMI (p=0.009) were independent predictors of intra-operative complications. Pathological diagnosis (p<0.001) and Charlson score (p=0.013) were independent predictors of death.

Conclusion:

Diligent care is needed with older patients, with multiple comorbidities and harboring unfavorable adrenal disorders (adrenocortical carcinoma and pheocromocytoma), who have greater risk of post-operative complications. Patients with elevated BMI and larger tumors have higher risk of intra, but not of post-operative complications.

Comparing VA and Non-VA Quality of Care: A Systematic Review

BACKGROUND

The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems.

METHODS

Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions.

RESULTS

Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions.

DISCUSSION

The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

Resident versus no resident: a single institutional study on operative complications, mortality, and cost

BACKGROUND

Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital.

METHODS

Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared.

RESULTS

Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2.

CONCLUSIONS

Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.

Previously unreported high-grade complications of adrenalectomy

BACKGROUND

Serious complications of adrenalectomy are rare but the incidence may be underestimated if they occur outside major referral centers. We report five cases of high-grade complications after adrenalectomy that have not been previously described.

METHODS

The records of five cases of adrenalectomy performed at outside hospitals were reviewed. Four cases were referred for management of complications and one for medical-legal review. The nature of the adrenal lesion, operative approach, complication(s), and subsequent clinical course and complication management were assessed. Both open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) cases were included.

RESULTS

Operative indications were pheochromocytoma (N = 3), aldosteronoma (N = 1), and a nonfunctioning 6-cm hypervascular mass (N = 1). Complications of adrenalectomy included: case 1--complete transection of the porta hepatitis during right LA resulting in hepatic failure requiring emergent liver transplantation; case 2--ligation of the hepatic artery during right OA resulting in recurrent cholangitis and bile duct sclerosis requiring liver transplantation; case 3--ligation of the left ureter during LA resulting in postoperative hydronephrosis and loss of renal function; case 4--loss of left kidney function after OA, likely secondary to renal artery ligation ultimately requiring laparoscopic nephrectomy; case 5--LA of a normal adrenal gland for a 6-cm hypervascular mass thought to be arising from the adrenal gland. Three-month postoperative imaging demonstrated a persistent mass and the patient underwent hand-assisted laparoscopic nephrectomy for a left upper pole renal cell carcinoma that was missed at the time of LA.

CONCLUSION

Despite the generally low morbidity of adrenalectomy, serious and potentially life-threatening complications can occur. Surgeon inexperience may be a factor in the occurrence of some of these complications which have not been previously described.

Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program

BACKGROUND

Numerous series demonstrate the benefits of laparoscopic versus open adrenalectomy, but fail to adjust for confounding factors. This study uses the Veterans Affairs National Surgical Quality Improvement Program database to compare these two approaches, adjusting for baseline differences.

STUDY DESIGN

Laparoscopic (n=358) and open (n=311) adrenalectomy data were collected at 123 Department of Veterans Affairs and 14 university hospitals from October 1, 2001 to September 30, 2004. Preoperative characteristics, operative data, and 30-day outcomes were compared using the chi-square or Fisher's exact test for categorical variables and the t-test for continuous variables. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were computed for the effect of operative approach on postoperative morbidity. Adjusted odds ratios and 95% CI were computed for this same effect, adjusting for variables that were predictive of outcomes or imbalanced at baseline. Data are reported as means +/-SD, unless otherwise indicated.

RESULTS

Patients undergoing open adrenalectomy were more likely to be older (57.8+/-11.9 years versus 53.5+/-13.2 years, p < 0.0001), harbor malignancy (44.5% versus 13.5%, p < 0.0001), have higher American Society of Anesthesiologists classifications (p=0.0037), smoke (35.4% versus 22.6%, p=0.0003), and have lower serum albumin levels (3.9+/-0.5 g/dL versus 4.0+/-0.5 g/dL, p=0.0241). Open procedures had increased operative times (3.9+/-1.8 hours versus 2.9+/-1.3 hours, p < 0.0001), transfusion requirements (0.7+/-1.8 U versus 0.1+/-0.5 U, p<0.0001), reoperations (4.8% versus 1.4%, p=0.0094), length of stay (9.4+/-11.0 days versus 4.1+/-4.7 days, p < 0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p < 0.0001) with unadjusted and adjusted odds ratio (95% CI) of 5.52 (2.94, 10.33), and 3.97 (1.92, 8.22), respectively. Open procedures resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections.

CONCLUSIONS

Even after adjustment for confounding factors, 30-day morbidity was much higher for patients having open adrenalectomy.

Liver Resection in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study

BACKGROUND

A congressional mandate, which led to the formation of the National Surgical Quality Improvement Program, is now being fulfilled with the publication of general and vascular surgical outcomes comparisons between Veterans Affairs (VA) and university medical centers. A series of National Surgical Quality Improvement Program articles evaluate the effect of hospital type (VA versus university hospitals) on procedure-specific outcomes. This article focuses on liver resections.

STUDY DESIGN

This is a prospective cohort study of a sample of patients undergoing liver resections at 128 VA medical centers compared with 14 university medical centers from October 1, 2001, to September 30, 2004. Preoperative and intraoperative characteristics were evaluated to identify possible variables related to morbidity and mortality and possible confounders of the hospital effect. These variables were then used to identify the effect that the hospital setting might have on surgical outcomes after liver resections.

RESULTS

Data from 237 liver resections at VA hospitals were compared with 783 procedures performed at university hospitals. The unadjusted 30-day morbidity rate tended to be higher in the VA (university 22.6% versus VA 27.9%; p = 0.10). After risk adjustment, results were equivalent (odds ratio = 0.94; p = 0.77). Unadjusted 30-day mortality rate was significantly higher in VA hospitals (6.8% versus 2.6%; p = 0.002). After risk adjustment, there was no longer a significant difference in mortality between the two hospital systems (odds ratio = 1.62; p = 0.33).

CONCLUSIONS

For liver resections, the National Surgical Quality Improvement Program and Patient Safety in Surgery Study data suggest that there is no significant difference in risk-adjusted morbidity or mortality rates between VA and the university medical centers.

The Patient Safety in Surgery Study: Background, Study Design, and Patient Populations

BACKGROUND

The purpose of this article is to describe the background, design, and patient populations of the Patient Safety in Surgery Study, as a preliminary to the articles in this journal that will report the results of the Study.

STUDY DESIGN

The Patient Safety in Surgery Study was a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in patients undergoing major general and vascular operations at 128 Veterans Affairs (VA) medical centers and 14 selected university medical centers between October 1, 2001 and September 30, 2004. An Internet-based data collection system was used to input data from the different private medical centers. Semiannual feedback of observed to expected mortality and morbidity ratios was provided to the participating medical centers.

RESULTS

During the 3-year study, total accrual in general surgery was 145,618 patients, including 68.5% from the VA and 31.5% from the private sector. Accrual in vascular surgery totaled 39,225 patients, including 77.8% from the VA and 22.2% from the private sector. VA patients were older and included a larger proportion of male patients and African Americans and Hispanics. The VA population included more inguinal, umbilical, and ventral hernia repairs, although the private-sector population included more thyroid and parathyroid, appendectomy, and operations for breast cancer. Preoperative comorbidities were similar in the two populations, but the rates of comorbidities were higher in the VA. American Society of Anesthesiologists classification tended to be higher in the VA.

CONCLUSIONS

The National Surgical Quality Improvement Program methodology was successfully implemented in the 14 university medical centers. The data from the study provided the basis for the articles in this issue of the Journal of the American College of Surgeons.