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Halpern AI, Klein M, McSweeney B, Tran HV, Ganguli S, Haney V, Noureldine SI, Vaziri K, Jackson HT, Lee J. Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs. Surg Endosc 2024; 38:2344-2349. [PMID: 38632119 DOI: 10.1007/s00464-024-10805-y] [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: 02/17/2024] [Accepted: 03/21/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades. METHODS Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ). RESULTS From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001). CONCLUSIONS ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.
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Affiliation(s)
- Alex I Halpern
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA.
| | - Margaret Klein
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
| | - Benjamin McSweeney
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Hoang-Viet Tran
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
| | - Sangrag Ganguli
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Victoria Haney
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
| | - Salem I Noureldine
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
| | - Hope T Jackson
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Juliet Lee
- Department of Surgery, George Washington University School of Medicine & Health Sciences, 2150 Pennsylvania Ave NW, Suite 6B, Washington, DC, 20037, USA
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Spivak J, Chan PH, Prentice HA, Paxton EW, Brill ER. Mesh-based inguinal hernia repairs in an integrated healthcare system and surgeon and hospital volume: a cohort study of 110,808 patients from over a decade. Hernia 2023; 27:1209-1223. [PMID: 37148362 DOI: 10.1007/s10029-023-02796-x] [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: 12/09/2022] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE The aim of this study was to describe a cohort of patients who underwent inguinal hernia repair within a United States-based integrated healthcare system (IHS) and evaluate the risk for postoperative events by surgeon and hospital volume within each surgical approach, open, laparoscopic, and robotic. METHODS Patients aged ≥ 18 years who underwent their first inguinal hernia repair were identified for a cohort study (2010-2020). Average annual surgeon and hospital volume were broken into quartiles with the lowest volume quartile as the reference group. Multiple Cox regression evaluated risk for ipsilateral reoperation following repair by volume. All analyses were stratified by surgical approach (open, laparoscopic, and robotic). RESULTS 110,808 patients underwent 131,629 inguinal hernia repairs during the study years; procedures were performed by 897 surgeons at 36 hospitals. Most repairs were open (65.4%), followed by laparoscopic (33.5%) and robotic (1.1%). Reoperation rates at 5 and 10 years of follow-up were 2.4% and 3.4%, respectively; rates were similar across surgical groups. In adjusted analysis, surgeons with higher laparoscopic volumes had a lower reoperation risk (27-46 average annual repairs: hazard ratio [HR] = 0.63, 95% confidence interval [CI] 0.53-0.74; ≥ 47 repairs: HR 0.53, 95% CI 0.44-0.64) compared to those in the lowest volume quartile (< 14 average annual repairs). No differences in reoperation rates were observed in reference to surgeon or hospital volume following open or robotic inguinal hernia repair. CONCLUSION High-volume surgeons may reduce reoperation risk following laparoscopic inguinal hernia repair. We hope to better identify additional risk factors for inguinal hernia repair complications and improve patient outcomes with future studies.
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Affiliation(s)
- J Spivak
- Department of Surgery, The Permanente Medical Group, Walnut Creek, CA, USA
| | - P H Chan
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, CA, USA
| | - H A Prentice
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, CA, USA
| | - E W Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, CA, USA
| | - E R Brill
- Department of Surgery, The Permanente Medical Group, Santa Clara, CA, 95051, USA.
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Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes. J Trauma Acute Care Surg 2022; 93:774-780. [PMID: 35972185 DOI: 10.1097/ta.0000000000003764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. METHODS A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high- and low-volume centers. RESULTS We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high- and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. CONCLUSION Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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5
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Brooks DE, Ritchie-McLean SN, Chevannes W, Parker MJ, Griffiths R. Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery. Acta Orthop Belg 2022; 88:311-317. [DOI: 10.52628/88.2.8978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.
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Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach. J Gastrointest Surg 2022; 26:693-701. [PMID: 35013880 DOI: 10.1007/s11605-021-05241-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.
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Rimini M, Casadei-Gardini A, Brandi G, Leone F, Fornaro L, Pella N, Silvestris N, Montagnani F, Lonardi S, Lai E, Galizia E, Santini D, Palloni A, Filippi R, Masi G, Aprile G, Aglietta M, Frega G, Fenocchio E, Vivaldi C, Satolli MA, Salani F, Scartozzi M, Faloppi L, Pellino A, Sperti E, Burgio V, Ratti F, Aldrighetti L, Cascinu S, Cucchetti A. Risk-adjusted analysis of survival variability among hospitals treating biliary malignancy. J Chemother 2022; 34:543-549. [PMID: 35156913 DOI: 10.1080/1120009x.2022.2036557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Biliary tract cancer's (BTC) treatment main stone for advanced stages is constituted by chemotherapy. Surgical centralization and physicians' confidence in the use of new technologies and molecular analysis turned out to be of interest and potentially influencing survival. After applying a random-effect model, the relationship between each clinical variable on the main outcome was investigated through multilevel mixed-effects logistic regression. The risk-standardized outcomes were calculated for each centre involved. In the unadjusted cohort the median survival was 8.6 months (95%C.I.: 7.8-9.3) with a 9-month survival rate of 48.3% (95%C.I.: 45.0-51.5). A substantial heterogeneity across hospitals was found (I2: 70.3%). In multilevel mixed effect logistic regression, male, being treated for gallbladder cancer, higher ECOG, increased NLR, CEA and Ca 19.9 and low value of haemoglobin showed to increase the odds for 9-month mortality. The model estimated that the residual variance observed in 9-month mortality was attributable for the 2.6% to the treating hospital. Through a multilevel mixed effect model, average risk-standardized mortality within 9 months was 50.1%. As noticeable, all hospital's risk-standardized mortality falls within 95%C.I., thus all participating centres provided similar outcomes when adjusted for patient case-mix. Heterogenicity between hospital did not affect the outcome in term of overall survival.
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Affiliation(s)
- Margherita Rimini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Brandi
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Leone
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Lorenzo Fornaro
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Nicola Silvestris
- Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Oncology, IRCCS Istituto Tumori "Giovanni Paolo II" of Bari, Bari, Italy
| | - Francesco Montagnani
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, BI, Italy
| | - Sara Lonardi
- Oncology Unit 3, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Eleonora Lai
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Eva Galizia
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Daniele Santini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Andrea Palloni
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto Filippi
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gianluca Masi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | | | - Massimo Aglietta
- Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Torino, Italy
| | - Giorgio Frega
- Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
| | - Caterina Vivaldi
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Maria Antonietta Satolli
- Department of Oncology, University of Turin, Torino, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Salani
- U.O. Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, IT, Italy
| | - Mario Scartozzi
- Medical Oncology, University Hospital and University of Cagliari, Cagliari, Italy
| | - Luca Faloppi
- Macerata General Hospital, Medical Oncology Unit, Macerata, Italy
| | - Antonio Pellino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.,Oncology Unit 1, Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Elisa Sperti
- Division of Medical Oncology, Ordine Mauriziano Hospital, Torino, Italy
| | - Valentina Burgio
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | | | | | - Stefano Cascinu
- Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy.,Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Oncology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
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Poles G, Kaur R, Ramsdale E, Schymura MJ, Temple LK, Fleming FJ, Aquina CT. Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer. Surgery 2021; 171:1200-1208. [PMID: 34838330 DOI: 10.1016/j.surg.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes. METHODS The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery. RESULTS In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001). CONCLUSION Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.
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Affiliation(s)
- Gabriela Poles
- Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Roma Kaur
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Erika Ramsdale
- Department of Medicine, Division of Oncology, University of Rochester Medical Center, Rochester, NY
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, NY
| | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY; Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
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9
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O'Malley SM, Sanders JO, Nelson SE, Rubery PT, O'Malley NT, Aquina CT. Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery. Spine (Phila Pa 1976) 2021; 46:1588-1597. [PMID: 33882540 DOI: 10.1097/brs.0000000000004077] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case control study. OBJECTIVE To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. SUMMARY OF BACKGROUND DATA No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. METHODS Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. RESULTS Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). CONCLUSION Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.
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Affiliation(s)
- Sandra M O'Malley
- Department of Trauma and Orthopaedics, Mater Misericordiae University Hospital, Dublin, Ireland
| | - James O Sanders
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Susan E Nelson
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Paul T Rubery
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Natasha T O'Malley
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Christopher T Aquina
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Rochester, NY
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10
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Christou N, Ris F, Naumann D, Robert-Yap J, Mathonnet M, Gillion JF. Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter? Hernia 2021; 26:233-242. [PMID: 34596783 PMCID: PMC8881239 DOI: 10.1007/s10029-021-02512-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/21/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related to the mesh and the surgical technique have rarely been described. METHODS A registry-based multicenter study using prospectively collected data, including SSIs and their potential risk factors, was conducted in the French Hernia-Club. RESULTS Between 2012 and 2019, 21,976 consecutive unselected adult patients aged 64.8 ± 15.4 years old (88.9% male) underwent GHR (83.5% unilateral). Fifty four percent were laparoscopic; 97.6% used mesh. The overall incidence of SSI was 0.26%. The incidence of SSI was respectively, 0.24% and 0.19% (p = 0.420) in open vs laparoscopic repairs; 0.19% and 0.25% (p = 0.638) for polyester vs polypropylene mesh; In adjusted multivariate analysis focusing on macroporous meshes (which were the most implanted meshes: 23,148 out of 24,099), there were no differences in terms of SSIs' rates regarding the technique: open versus laparoscopy (p = 0.762) nor the type of mesh used: polypropylene versus polyester (p = 0.557). CONCLUSION The rate of SSI following GHR was low in this large registry study. Mesh type and surgical technique did not affect SSIs rates. Caution is advised when interpreting these data due to this very low rate of SSI and the potential for a type II error.
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Affiliation(s)
- N Christou
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Avenue Martin Luther King, 87042, Limoges Cedex, France. .,University Hospitals Birmingham NHS Foundation Trust, Birmingham, B152TH, UK.
| | - F Ris
- Department of Visceral Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle Perret, 4, 1205, Geneva, Switzerland
| | - D Naumann
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, B152TH, UK
| | - J Robert-Yap
- Department of Visceral Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle Perret, 4, 1205, Geneva, Switzerland
| | - M Mathonnet
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Avenue Martin Luther King, 87042, Limoges Cedex, France
| | - J-F Gillion
- Unité de Chirurgie Viscérale Et Digestive, Hôpital Privé d'Antony, 1, Rue Velpeau, 92160, Antony, France
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11
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Aquina CT, Becerra AZ, Fleming FJ, Cloyd JM, Tsung A, Pawlik TM, Ejaz A. Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery. Cancer 2021; 127:4059-4071. [PMID: 34292582 DOI: 10.1002/cncr.33766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. METHODS Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. RESULTS Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. CONCLUSIONS Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.
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Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Christophersen C, Baker JJ, Fonnes S, Andresen K, Rosenberg J. Lower reoperation rates after open and laparoscopic groin hernia repair when performed by high-volume surgeons: a nationwide register-based study. Hernia 2021; 25:1189-1197. [PMID: 33835325 DOI: 10.1007/s10029-021-02400-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair. METHODS This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18 years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and > 100 cases/year. RESULTS We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the > 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the > 100 category. CONCLUSION The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with < 100 cases/year compared with > 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.
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Affiliation(s)
- C Christophersen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - J J Baker
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - S Fonnes
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - K Andresen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.,The Danish Hernia Database, 2730 Herlev, Denmark
| | - J Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.,The Danish Hernia Database, 2730 Herlev, Denmark
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13
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Lindheim-Minde B, Gjøra A, Bakker JM, van Duinen AJ, van Leerdam D, Smalle IO, Bundu I, Bolkan HA. Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017. Surgery 2021; 170:126-133. [PMID: 33785194 DOI: 10.1016/j.surg.2021.02.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommends a minimum of 20 surgical specialists and 5,000 annual operations per 100,000 population by 2030. In 2012, Sierra Leone was far from reaching these targets. This study aimed to assess the changes in surgical activity, surgical workforce, and surgical productivity between 2012 and 2017. METHODS A nationwide, retrospective mapping of surgical activity and workforce in 2012 was repeated in 2017. All 60 facilities performing comprehensive surgery in Sierra Leone in 2017 were identified and data was obtained from surgical records and through structured interviews with facility directors. Annual estimates were calculated and compared with 2012. RESULTS The surgical workforce increased from 164.5 to 312.8 full-time positions. The annual volume of surgeries was enhanced by 15.6% (95% CI: 7.8-23.4%) from 24,152 to 27,928 (26,048-29,808) operations. With simultaneous population growth, this led to a decrease in surgical volume from 400 to 372 procedures per 100,000 population and an unmet operative need of 92.7%. The mean productivity of surgical providers went from 2.8 to 1.7 surgeries per week per full-time position. An increasing number of caesarean deliveries were performed in public institutions, by associate clinicians. CONCLUSION The unmet need for surgery in Sierra Leone remains very high, despite an increase in the surgical workforce, subsidizing maternal healthcare, and initiation of a surgical task-sharing program. The decline in surgical productivity with simultaneous increases in the surgical workforce calls for further exploration of the barriers to access and delivery of surgical care in Sierra Leone.
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Affiliation(s)
- Barbro Lindheim-Minde
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway and Freetown, Sierra Leone
| | - Andreas Gjøra
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway and Freetown, Sierra Leone
| | - Juul M Bakker
- Department of Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands; Royal Tropical Institute, Amsterdam, the Netherlands
| | - Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway and Freetown, Sierra Leone; Department of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | | | - Isaac O Smalle
- National Surgical Forum, Ministry of Health and Sanitation, Freetown, Sierra Leone; Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Ibrahim Bundu
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone; College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway and Freetown, Sierra Leone; Department of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway.
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14
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Martínez-Hoed J, Cordero-Bermúdez K, García-Pastor P, Pous-Serrano S, Ortiz-Cubero JA. The inguinal hernia management in Costa Rica according to a survey between surgeons: result comparison with 2018 International Groin Hernia Guidelines. BMC Surg 2021; 21:152. [PMID: 33743667 PMCID: PMC7981829 DOI: 10.1186/s12893-021-01156-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background Inguinal hernia surgery is a frequent procedure among general surgeons in Costa Rica, but the management and technique are not uniform. The International Guideline for Groin Hernia management was published in 2018 to standardize the inguinal hernia surgery, but the diffusion of the guidelines and its adherence have been extremely varied. Purpose Collect and analyze the current reality regarding groin hernia management in Costa Rica. Secondly evaluate the diffusion and development comparing it to the guideline’s recommendations. Method Questionnaire of 42 single and multiple answer questions according to the topics of the International Guideline directed
to general surgeons. Diffusion of the inquiry through surgical and hernia association chats and email. Timeframe June–December 2019. Results 64 surveys were collected, which is a representative number of the general surgeons national college. The most frequent procedure between these was the abdominal wall surgery. Every surgeon did more than 52 groin hernia surgeries in one year, most of them outpatients. The epidural anesthesia was used the most and Lichtenstein’s technique was the most frequently used (64%). 68% of the surgeons know how to perform a minimally invasive inguinal hernia surgery but with variable volumes. 38% of participants considered themselves experts in groin hernia management and 52% did not know the 2018 International Guideline. The recommendations of such guideline are followed only partially. Conclusions The 2018 Hernia Surge International Guidelines have low diffusion among Costa Rican surgeons. The laparoscopic approach is widely accepted but there are no studies to assess the results and the quality. There should be protocols and studies adapted to Costa Rica’s national situation. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01156-9.
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Affiliation(s)
- Jesús Martínez-Hoed
- General Surgery Department, R. A. Calderón Guardia Hospital, San José, Costa Rica. .,Integrated Group for Complex Hernia Treatment, Calderón Guardia Hospital, San José, Costa Rica. .,General Surgery, Metropolitan Hospital, San José, Costa Rica. .,Costa Rica Hernia Association, San José, Costa Rica.
| | - Katherine Cordero-Bermúdez
- General Surgery Department, R. A. Calderón Guardia Hospital, San José, Costa Rica.,Costa Rica Hernia Association, San José, Costa Rica.,General Surgery, Clínica Bíblica Hospital, San José, Costa Rica
| | - Providencia García-Pastor
- General Surgery At Hospital Politécnico y Universitario La Fe, Valencia, Spain.,Short Stay and Wall Surgery Unit, Hospital Politécnico y Universitario La Fe, Valencia, Spain
| | - Salvador Pous-Serrano
- General Surgery At Hospital Politécnico y Universitario La Fe, Valencia, Spain.,Short Stay and Wall Surgery Unit, Hospital Politécnico y Universitario La Fe, Valencia, Spain
| | - José A Ortiz-Cubero
- General Surgery Department, R. A. Calderón Guardia Hospital, San José, Costa Rica.,Integrated Group for Complex Hernia Treatment, Calderón Guardia Hospital, San José, Costa Rica
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15
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Lower recurrence rate after groin and primary ventral hernia repair performed by high-volume surgeons: a systematic review. Hernia 2021; 26:29-37. [PMID: 33404970 DOI: 10.1007/s10029-020-02359-4] [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: 11/10/2020] [Accepted: 12/09/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Hernia repair is a common procedure; however, an overview is lacking regarding the impact of annual surgeon volume and total surgical experience on the outcome of hernia repair. We aimed to explore the impact of annual surgeon volume and total surgical experience on outcomes of groin and primary ventral hernia repair. METHODS This systematic review followed the Prefered Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A protocol was registered at PROSPERO (CRD42020176140). PubMed, EMBASE, and Cochrane CENTRAL were searched. We investigated recurrence rates after groin and primary ventral hernia repair reported according to annual surgeon volume or total surgical experience with at least 6 months follow-up. Surgeons were pooled in three overlapping categories: high-volume (> 50 cases/year), medium-volume (11-50 cases/year) and low-volume (≤ 25 cases/year). RESULTS Ten records for groin hernia and one for primary ventral hernia were included. The median (range) recurrence rates after laparoscopic groin hernia repair for high, medium, and low-volume surgeons were 2.6% (2.3-3.0), 2.4% (0.7-4.6), and 4.2% (1.0-6.8), respectively. The median (range) recurrence rate after open groin hernia repair for high, medium, and low-volume surgeons were 2.1% (2.0-2.2), 1.7% (1.6-2.3), and 2.4% (2.2-5.0). The groin hernia recurrence rate seemed to increase when annual surgeon volume decreased below 25 cases/year. For primary ventral hernia, increased annual surgeon volume was associated with decreased reoperation rate. CONCLUSION High-volume surgeons seemed to have lower rates of hernia recurrence after groin as well as primary ventral hernia repair and our data supports the need for centralization of groin hernia repair on individual surgeons.
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16
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A new semiresorbable mesh for primary inguinal repair: a preliminary observational study on quality of life and safety. Hernia 2020; 24:1019-1031. [PMID: 32767180 DOI: 10.1007/s10029-020-02276-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/22/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND A currently unsolved problem of open inguinal hernia repair (IHR) is chronic postoperative inguinal pain (CPIP), which affects 10-12% of patients after IHR. In the present paper, we explored the results of a newly designed partially absorbable mesh made of polypropylene and polylactic acid (HybridMesh®) for open hernia repair and its impact on postoperative safety, efficacy, comfort and pain. METHODS A prospective multicentric pilot trial was conducted in third-referral centers across Italy (n = 5). Inclusion criteria were unilateral primary inguinal hernia in patients of both genders and BMI < 30 kg/m2. All patients were submitted to elective Lichtenstein mesh hernia repair under local anesthesia with HybridMesh. Primary outcome measure was the evaluation of Carolina Comfort Scale and modifications at 2 years after surgery and its correlation with surgical variables; secondary outcomes were postoperative early and late morbidity, recurrence and postoperative early quality of life. RESULTS Between 2015 and 2016, 125 (5 female) patients were operated, 2-year follow-up rate was 100%. The surgical site occurrence rate was 28% without the need of procedural interventions. Twenty-four months after surgery, no case of severe CPIP was recorded and altered global CCS score was present in 16 patients (13.0%). At univariate analysis, CCS score was negatively affected by fixation with sutures (OR 3.949; 95% CI 1.334-13.300), with no effect shown on multivariate analysis. Alterations in pain and movement limitations domains of CCS were observed in 9.7% of patients, at univariate analysis; they occurred more frequently when the mesh was sutured (OR 4.437; 95% CI 1.387-17.025) and in patients suffering from SSO (ecchymosis: OR 3.269; 95% CI 1.032-10.405); however, no effect was shown on multivariate analysis. Two recurrences (1.6%) were identified within the first postoperative year. CONCLUSIONS The results of this study support the safety, efficacy and good tolerability of HybridMesh as a device to treat primary unilateral inguinal hernia during open anterior approach. Further studies are needed to clarify its role in comparison to currently available devices at longer follow-ups.
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17
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Sarwahi V, Galina J, Wendolowski S, Dimauro JP, Moguilevich M, Katyal C, Thornhill B, Lo Y, Amaral TD. A dual-team approach benefits standard-volume surgeons, but has minimal impact on outcomes for a high-volume surgeon in AIS patients. Spine Deform 2020; 8:447-453. [PMID: 32026443 DOI: 10.1007/s43390-020-00049-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/30/2019] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective chart review of prospectively collected data. OBJECTIVE This study seeks to evaluate the effect of number of surgeons, surgeon experience, and surgeon volume on AIS surgery. Recent literature suggests that utilizing two surgeons for spine deformity correction surgery can improve perioperative outcomes. However, the surgeon's experience and surgical volume are likely as important. METHODS AIS patients undergoing PSF from 2009 to 2019 were included. Patient demographics, X-ray and perioperative outcomes were collected and collated based on primary surgeon. Analysis was performed for single versus dual surgeons, surgeon experience (≤ 10 years in practice), and surgical volume (less/greater than 50 cases/year). Median (IQR) values, Wilcoxon Rank Sums test, Kruskal-Wallis test, and Fisher's exact test were utilized. RESULTS 519 AIS cases, performed by 4 surgeons were included. Two surgeons were highly experienced, 1 of whom was also high volume. Five cohorts were studied: a single senior high volume (S1) (n = 302), dual-junior surgeons (DJ) (n = 73), dual senior-junior (SJ) (n = 36), dual-senior (DS) (n = 21) and a single senior, standard-volume surgeon alone (S2) (n = 87). Radiographic parameters were similar between the groups (p > 0.05). Preoperative Cobb was significantly higher for DS compared to S1 (p = 0.034) Pre- and post-op kyphosis were similar (p > 0.05). Cobb correction was similar (p > 0.05). Levels fused, fixation points, anesthesia and surgical times were similar (p > 0.05). When the standard-volume surgeon operated with a second surgeon, radiographic parameters were similar (p > 0.05), but anesthesia time, surgical time, and hospital length of stay were significantly shorter (p < 0.05). Additionally, DJ had significantly shorter anesthesia and operative times (p < 0.001) and length of stay (p < 0.001) compared to S2. CONCLUSION Standard-volume surgeons have better outcomes with a dual surgeon approach. Junior surgeons benefit operating with an experienced surgeon. A high-volume surgeon, however, does not benefit from a dual surgeon approach. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Vishal Sarwahi
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA.
| | - Jesse Galina
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Stephen Wendolowski
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Jon-Paul Dimauro
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Marina Moguilevich
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Chhavi Katyal
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Beverly Thornhill
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Terry D Amaral
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
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18
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Revisiting the Relationship Between Hospital Case Volume and Outcomes in Abdominally Based Free Flap Breast Reconstruction. Ann Plast Surg 2020; 85:397-401. [PMID: 32102003 DOI: 10.1097/sap.0000000000002308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increased operative volume has been associated with benefits in patient outcomes for a variety of surgical procedures. In autologous abdominally based breast reconstruction, however, there are few studies assessing the association between procedure volume and patient outcomes. The objectives of this study are to evaluate the associations between abdominal-based free flap breast reconstruction and patient outcomes. METHODS The 2013-2014 Healthcare Cost and Utilization Project National Inpatient Sample was queried for all female patients with a diagnosis of breast cancer who underwent mastectomy and immediate abdominally based breast reconstruction (deep inferior epigastric perforator or transverse rectus abdominus muscle free flaps). Outcomes included occurrence of major or surgical site in-hospital complications, hospital cost, and length of stay (LOS). High-volume (HV) hospitals were defined as the 90th percentile of annual case volume or higher (>18 cases/y). Multivariate regressions and generalized linear modeling with gamma log-link function were performed to access the outcomes associated with HV hospitals. RESULTS Overall, 7145 patients at 473 hospitals were studied; of these, 42.4% of patients were treated at HV hospitals. There were significant differences in unadjusted major complications (2.1% vs 4.3%; P < 0.001) and unadjusted surgical site complications (3.5% vs 6.1%; P < 0.001) between HV and non-HV hospitals. After adjustments for clinical and hospital characteristics, patients treated at HV hospitals were less likely to experience a major complication (odds ratio, 0.488; 95% confidence interval, 0.353-0.675; P < 0.001) or surgical site complication (odds ratio, 0.678; 95% confidence interval, 0.519-0.887; P = 0.005). There was no difference in inpatient cost between HV and non-HV hospitals ($26,822 vs $26,295; marginal cost, $528; P = 0.102); however, HV hospitals had a shorter LOS (4.31 vs 4.40 days; marginal LOS, -0.10 days; P = 0.005). CONCLUSIONS Hospitals that perform a larger volume of immediate abdominal-based breast reconstructions after mastectomy, when compared with those that perform a lower volume of these procedures, seem to have an associated lower rate of major complications and a shorter LOS. However, these same HV centers demonstrate no decrease in costs. Further research is needed to understand how these HV centers can reduce hospital costs.
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19
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Wren SM, Kushner AL. The Realities of External Validity in Global Surgery Research-Reply. JAMA Surg 2020; 155:172-173. [PMID: 31642875 DOI: 10.1001/jamasurg.2019.4090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sherry M Wren
- Center for Global Health and Innovation, Stanford University School of Medicine, Palo Alto, California.,Clinical Surgery, Palo Alto Veterans Hospital, Palo Alto, California
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20
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Maneck M, Köckerling F, Fahlenbrach C, Heidecke CD, Heller G, Meyer HJ, Rolle U, Schuler E, Waibel B, Jeschke E, Günster C. Hospital volume and outcome in inguinal hernia repair: analysis of routine data of 133,449 patients. Hernia 2019; 24:747-757. [PMID: 31786700 PMCID: PMC7395912 DOI: 10.1007/s10029-019-02091-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/17/2019] [Indexed: 01/20/2023]
Abstract
Introduction Inguinal hernias are repaired using either open or minimally invasive surgical techniques. For both types of surgery it has been demonstrated that a higher annual surgeon volume is associated with a lower risk of recurrence. This present study investigated the volume-outcome implications for recurrence operations, surgical complications, rate of chronic pain requiring treatment, and 30-day mortality based on the hospital volume. Materials and methods The data basis used was the routine data collected throughout the Federal Republic of Germany for persons insured by the Local General Sickness Fund “AOK” who had undergone inpatient inguinal hernia repair between 2013 and 2015. Complications were recorded by means of indicators. Hospitals were divided into five groups on the basis of the annual caseload volume: 1–50, 51–75, 76–100, 101–125, and ≥ 126 inguinal hernia repairs per year. The effect of the hospital volume on the indicators was assessed using multiple logistic regression. Results 133,449 inguinal hernia repairs were included. The incidence for recurrence operations was 0.95%, for surgical complications 4.22%, for chronic pain requiring treatment 2.87%, and for the 30-day mortality 0.28%. Low volume hospitals (1–50 and 51–75 inguinal hernia repairs per year) showed a significantly increased recurrence risk compared to high volume hospitals with ≥ 126 inguinal hernia repairs per year (odds ratio: 1.53 and 1.24). No significant correlations were found for the other results. Conclusions The study gives a detailed picture of hospital care for inguinal hernia repair in Germany. Furthermore, it was noted that the risk of hernia recurrence decreases in line with a rising caseload of the treating hospital.
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Affiliation(s)
- M Maneck
- AOK Research Institute (WIdO), Berlin, Germany
| | - F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany.
| | | | - C D Heidecke
- Department of General, Visceral, Thoracic and Vascular Surgery, University of Greifswald, Greifswald, Germany
| | - G Heller
- Department of Medicine, University of Marburg, Marburg, Germany
| | - H J Meyer
- German Society of Surgery, Berlin, Germany
| | - U Rolle
- Department of Pediatric Surgery and Pediatric Urology, University of Frankfurt/Main, Frankfurt/Main, Germany
| | - E Schuler
- Department of Quality Management, Helios Hospitals, Berlin, Germany
| | - B Waibel
- Medical Review Board of the Social Health Insurance Funds Baden-Württemberg, Freiburg, Germany
| | - E Jeschke
- AOK Research Institute (WIdO), Berlin, Germany
| | - C Günster
- AOK Research Institute (WIdO), Berlin, Germany
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Merola G, Cavallaro G, Iorio O, Frascio M, Pontecorvi E, Corcione F, Andreuccetti J, Pignata G, Stabilini C, Bracale U. Learning curve in open inguinal hernia repair: a quality improvement multicentre study about Lichtenstein technique. Hernia 2019; 24:651-659. [DOI: 10.1007/s10029-019-02064-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/27/2019] [Indexed: 01/01/2023]
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Causes of recurrences after open inguinal herniorrhaphy. Hernia 2018; 23:637-645. [DOI: 10.1007/s10029-018-1868-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/25/2018] [Indexed: 12/15/2022]
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Schmidt L, Öberg S, Andresen K, Rosenberg J. Recurrence Rates After Repair of Inguinal Hernia in Women: A Systematic Review. JAMA Surg 2018; 153:1135-1142. [PMID: 30383113 DOI: 10.1001/jamasurg.2018.3102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance To our knowledge, a systematic review has not yet been performed that specifically addresses the management of inguinal hernia in women. Recurrence after repair of inguinal hernia is not unusual in women and may be a previously undiagnosed femoral hernia, which is rarely seen in men. Objective To investigate rates and types of recurrences in women who had undergone repair of primary inguinal hernia. Evidence Review PubMed, Embase, and the Cochrane databases were searched in September 2017 for studies reporting recurrences after repair of primary inguinal hernia in women. Crude rates of recurrence (number of recurrences/number of women) were calculated after open and laparoscopic repairs, and the type of recurrent hernia was registered, if noted in the studies. This review is reported according to the PRISMA guideline. Findings A total of 55 studies were included, comprising 43 870 women (mean age, 42-69 years; median age, 57 years). Five studies were randomized clinical trials, 14 were prospective cohort studies, 7 were prospective database studies, and 29 were retrospective cohort studies. Twenty studies reported recurrence after laparoscopic repair, with a crude recurrence rate of 1.2% (27 of 2257) (range, 0%-5%) and a median follow-up of 24 months. Thirty-seven studies reported open repair, with a crude recurrence rate of 2.4% (818 of 33 971) (range, 0%-12.5%) and a median follow-up of 36 months. The crude recurrence rate in randomized clinical trials and prospective studies was 1.2% (18 of 1525) after laparoscopic repair compared with 4.9% (490 of 10 058) after open repair. The recurrent inguinal hernia was a femoral hernia in 203 of 496 patients (40.9%) after open repair, compared with 0% of patients after laparoscopic repair. Recurrence rates were similar when open mesh vs nonmesh techniques were used. Conclusions and Relevance Recurrence rates after repair of primary inguinal hernia in women are lower after laparoscopic repair compared with open repair. Intraoperative findings during repair of recurrent inguinal hernia are often femoral hernias in women.
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Affiliation(s)
- Line Schmidt
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Stina Öberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Kristoffer Andresen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
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Authen AL, Dybvik E, Furnes O, Gjertsen JE. Surgeon's experience level and risk of reoperation after hip fracture surgery: an observational study on 30,945 patients in the Norwegian Hip Fracture Register 2011-2015. Acta Orthop 2018; 89:496-502. [PMID: 29860911 PMCID: PMC6202762 DOI: 10.1080/17453674.2018.1481588] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Ane L Authen
- Department of Clinical Medicine, University of Bergen, Bergen;;
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen;; ,Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen;; ,Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway,Correspondence:
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Reoperation for inguinal hernia recurrence in Ontario: a population-based study. Hernia 2018; 23:647-654. [PMID: 30244343 DOI: 10.1007/s10029-018-1822-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/14/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures. METHODS We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates. RESULTS We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26). CONCLUSION Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.
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The impact of hospital volume on clinical and economic outcomes in ventral hernia repair: an analysis with national policy implications. Hernia 2018; 22:793-799. [DOI: 10.1007/s10029-018-1803-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/04/2018] [Indexed: 11/24/2022]
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Stabilini C, Cavallaro G, Bocchi P, Campanelli G, Carlucci M, Ceci F, Crovella F, Cuccurullo D, Fei L, Gianetta E, Gossetti F, Greco DP, Iorio O, Ipponi P, Marioni A, Merola G, Negro P, Palombo D, Bracale U. Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences. Int J Surg 2018; 54:222-235. [PMID: 29730074 DOI: 10.1016/j.ijsu.2018.04.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/06/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.
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Affiliation(s)
| | | | | | | | - Michele Carlucci
- Department of General and Emergency Surgery, IRCCS San Raffaele, Milan, Italy
| | - Francesca Ceci
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | | | - Diego Cuccurullo
- Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Landino Fei
- Department of Anaesthesiological, Surgical and Emergency Sciences, Second University of Naples, Italy
| | - Ezio Gianetta
- Department of Surgical Sciences, University of Genoa, Italy
| | | | | | - Olga Iorio
- General Surgery Unit, Aprilia Hospital, Aprilia (RM), Italy
| | - Pierluigi Ipponi
- General Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Giovanni Merola
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
| | - Paolo Negro
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Denise Palombo
- Department of Surgical Sciences, University of Genoa, Italy
| | - Umberto Bracale
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
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Anitha B, Aravindhan K, Sureshkumar S, Ali MS, Vijayakumar C, Palanivel C. The Ideal Size of Mesh for Open Inguinal Hernia Repair: A Morphometric Study in Patients with Inguinal Hernia. Cureus 2018; 10:e2573. [PMID: 29974028 PMCID: PMC6029728 DOI: 10.7759/cureus.2573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/03/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction This study was done to analyze the morphometric features of the inguinal canal with different types of inguinal hernias to determine the appropriate size of mesh required to cover potential sites of recurrence. A morphometric assessment in the particular population is essential to recommend the appropriate mesh size in inguinal hernias to cover all the potential sites of recurrence. Materials and methods This was a prospective observational study, including all consecutive patients undergoing open inguinal hernia repair under local/regional/general anesthesia over a period of three years. Surgeries that were done in emergencies for complicated hernias, laparoscopic repair, and recurrent inguinal hernias were excluded. Intra-operative parameters were studied to predict the appropriate mesh size, which included the position of the superficial and deep inguinal ring (SIR and DIR) with the diameter, the distance of SIR and DIR from the anterior superior iliac spine (ASIS), and the distance from the summit of the muscular arch to the inguinal ligament. The differences in morphometric details between the types of hernias and categorical variables were assessed using the chi-square test. Results The study included a total of 170 patients with a mean age of 50.67 + 17.59 years. An indirect hernia was the most common type in patients less than 60 years. The mean distance from ASIS to SIR was 10.2+ 1.9 cm, and in indirect hernia patients, it was found to be significantly increased (p=0.042). The mean distance from ASIS to DIR was 4.14+1.57 cm, where the indirect hernia patients had a significantly less distance (p=0.029). The mean length of the inguinal canal in a direct hernia was 5.66 + 0.5 cm, whereas, in an indirect inguinal hernia, it was 6.46 + 0.8 cm, which was significant (p=0.029). The mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch was 4.03 cm, and there was no significant difference between the indirect and direct hernia patients. Conclusion After considering the morphometric assessments of the length of the inguinal canal, the mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch, the mean distance from ASIS to DIR, the ideal mesh size for the population would be 9 X 15 cm to cover all the potential sites of recurrence.
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Affiliation(s)
- Balaiya Anitha
- Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Karuppusamy Aravindhan
- Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | | | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chinnakali Palanivel
- Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Aquina CT, Fleming FJ, Becerra AZ, Hensley BJ, Noyes K, Monson JR, Temple LK, Cellini C. Who gets a pouch after colectomy in New York state and why? Surgery 2018; 163:305-310. [DOI: 10.1016/j.surg.2017.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
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Abstract
BACKGROUND Ventral hernia repair is a common procedure and is undertaken by surgeons with varying training backgrounds. Outcomes after hernia repair depend on numerous factors, some being patient or surgeon specific. It remains unclear what the ideal roles are for general and plastic surgeons in open ventral hernia repair. We hypothesized that open ventral hernia repair by plastic surgeons is safe and comparable with general surgeons. METHODS We performed a retrospective observational study using data from the National Surgical Quality Improvement Program database from 2007 to 2013. Patients with a primary diagnosis of ventral hernia undergoing open repair were identified. Multivariate regression modeling was performed, adjusting for surgeon specialty, patient characteristics, common concurrent procedures, and the total number of concurrent procedures. Outcomes studied were major and minor 30-day complications, operation time, readmission, unplanned reoperation, and length of hospital stay. RESULTS We identified 53,746 patients who underwent open repair, 53,282 (99.1%) by general surgeons (GS) and 464 (0.9%) by plastic surgeons (PS). There were significantly different rates of concurrent panniculectomy (12.1% PS vs 2.4% GS) and component separation (24.8% PS vs 5.3% GS), representing increased PS case complexity. 52.3% of GS and 92.9% of PS performed panniculectomy without an alternate specialty surgeon. 81.3% of GS and 97.4% of PS performed component separation without an alternate specialty surgeon. The PS patients had a significantly longer uncorrected length of stay and operation time than GS patients (all P < 0.001). Similarly, PS was positively associated with uncorrected major and minor complications (P < 0.001). However, these relationships did not persist on multivariate analysis after adjusting for demographic characteristics, medical comorbidities, concurrent procedures, and total procedure load. Furthermore, PS was associated with lower odds of major complications (operating room, 0.49; P = 0.05) compared with GS. CONCLUSIONS Outcomes of hernia repair by plastic surgeons are comparable with general surgeons, despite plastic surgeons being involved in many complex cases. Interestingly, we identified that general surgeons are performing adjunctive procedures to ventral hernia previously handled by plastic surgeons. Although further study is warranted, we conclude that for open ventral hernia repair, plastic surgeons provide a comparable alternative to general surgeons.
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Long-term Deleterious Impact of Surgeon Care Fragmentation After Colorectal Surgery on Survival: Continuity of Care Continues to Count. Dis Colon Rectum 2017; 60:1147-1154. [PMID: 28991078 DOI: 10.1097/dcr.0000000000000919] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical care fragmentation at readmission impacts short-term outcomes. However, the long-term impact of surgical care fragmentation is unknown. OBJECTIVE The purpose was to evaluate the impact of surgical care fragmentation, encompassing both surgeon and hospital care, at readmission after colorectal surgery on 1-year survival. DESIGN This was a retrospective cohort study. SETTING The study included patients undergoing colorectal resection in New York State from 2004 to 2014. PATIENTS Included were 20,016 patients undergoing colorectal resection who were readmitted within 30 days of discharge and categorized by source-of-care fragmentation. Each readmission was classified by the source of fragmentation: readmission to the index hospital and managed by another provider, readmission to another hospital by the index surgeon, and readmission to another hospital by another provider. Patients readmitted to the index hospital and managed by the index surgeon served as controls. MAIN OUTCOME MEASURES One-year overall survival and 1-year colorectal cancer-specific survival were the outcomes measured. RESULTS After propensity adjustment, surgeon care fragmentation was independently associated with decreased survival. In comparison with patients without surgical care fragmentation (patients readmitted to the index hospital and managed by the index surgeon), patients readmitted to the index hospital and managed by another provider had over a 2-fold risk (HR, 2.33; 95% CI, 2.10-2.60) and patients readmitted to another hospital by another provider had almost a 2-fold risk (HR, 1.91; 95% CI, 1.63-2.25) of 1-year mortality. Among 9545 patients with a colorectal cancer diagnosis, surgical care fragmentation was once again associated with decreased survival with patients readmitted to the index hospital and managed by another provider having a HR of 2.12 (95% CI, 1.76-2.56) and patients readmitted to another hospital by another provider having a HR of 1.57 (95% CI, 1.17-2.11) compared with patients readmitted to the index hospital and managed by the index surgeon. LIMITATIONS Limitations include possible miscoding of data, retrospective design, and selection bias. CONCLUSIONS After accounting for patient, index hospital, index surgeon, and readmission factors, there is a significant 2-fold decrease in survival associated with surgeon care fragmentation regardless of hospital continuity. See Video Abstract at http://links.lww.com/DCR/A431.
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Aquina CT, Blumberg N, Becerra AZ, Boscoe FP, Schymura MJ, Noyes K, Monson JRT, Fleming FJ. Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection. Ann Surg 2017; 266:311-317. [PMID: 27631770 DOI: 10.1097/sla.0000000000001990] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery. BACKGROUND Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients. METHODS The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival. RESULTS Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival. CONCLUSIONS Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY ‡New York State Cancer Registry, New York State Department of Health, Albany, NY §Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida College of Medicine, Orlando, FL
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Antiporda M, Veenstra B, Jackson C, Kandel P, Daniel Smith C, Bowers SP. Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc 2017; 32:945-954. [PMID: 28733735 DOI: 10.1007/s00464-017-5770-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/14/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. METHODS We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7). RESULTS At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). CONCLUSIONS Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.
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Affiliation(s)
- Michael Antiporda
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Benjamin Veenstra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chloe Jackson
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Pujan Kandel
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Steven P Bowers
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up. Neurosurgery 2017; 83:69-75. [DOI: 10.1093/neuros/nyx338] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/16/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO.
OBJECTIVE
To investigate if performance of 3CO surgeries improves with years of practice.
METHODS
Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis.
RESULTS
Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001).
CONCLUSION
Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.
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Aquina CT, Becerra AZ, Probst CP, Xu Z, Hensley BJ, Iannuzzi JC, Noyes K, Monson JRT, Fleming FJ. Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team. Ann Surg 2017; 264:437-47. [PMID: 27433901 DOI: 10.1097/sla.0000000000001861] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions. SUMMARY BACKGROUND DATA Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies. METHODS Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions. RESULTS Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32). CONCLUSIONS This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
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Aquina CT, Fleming FJ, Becerra AZ, Xu Z, Hensley BJ, Noyes K, Monson JRT, Jusko TA. Explaining variation in ventral and inguinal hernia repair outcomes: A population-based analysis. Surgery 2017; 162:628-639. [PMID: 28528663 DOI: 10.1016/j.surg.2017.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/06/2017] [Accepted: 03/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair. METHODS The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003-2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence. RESULTS Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models. CONCLUSION The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Bradley J Hensley
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Katia Noyes
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
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Niebuhr H, Köckerling F. Surgical risk factors for recurrence in inguinal hernia repair - a review of the literature. Innov Surg Sci 2017; 2:53-59. [PMID: 31579737 PMCID: PMC6754004 DOI: 10.1515/iss-2017-0013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/09/2017] [Indexed: 02/02/2023] Open
Abstract
Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed.
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Affiliation(s)
- Henning Niebuhr
- Hanse-Hernia Center, Alte Holstenstrasse 16, D-21031 Hamburg, Germany
| | - Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, D-13585 Berlin, Germany
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Köckerling F, Bittner R, Kraft B, Hukauf M, Kuthe A, Schug-Pass C. Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair? Surg Endosc 2017; 31:573-585. [PMID: 27334968 PMCID: PMC5266765 DOI: 10.1007/s00464-016-5001-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/23/2016] [Indexed: 01/23/2023]
Abstract
INTRODUCTION For open and endoscopic inguinal hernia surgery, it has been demonstrated that low-volume surgeons with fewer than 25 and 30 procedures, respectively, per year are associated with significantly more recurrences than high-volume surgeons with 25 and 30 or more procedures, respectively, per year. This paper now explores the relationship between the caseload and the outcome based on the data from the Herniamed Registry. PATIENTS AND METHODS The prospective data of patients in the Herniamed Registry were analyzed using the inclusion criteria minimum age of 16 years, male patient, primary unilateral inguinal hernia, TEP or TAPP techniques and availability of data on 1-year follow-up. In total, 16,290 patients were enrolled between September 1, 2009, and February 1, 2014. Of the participating surgeons, 466 (87.6 %) had carried out fewer than 25 endoscopic/laparoscopic operations (low-volume surgeons) and 66 (12.4 %) surgeons 25 or more operations (high-volume surgeons) per year. RESULTS Univariable (1.03 vs. 0.73 %; p = 0.047) and multivariable analysis [OR 1.494 (1.065-2.115); p = 0.023] revealed that low-volume surgeons had a significantly higher recurrence rate compared with the high-volume surgeons, although that difference was small. Multivariable analysis also showed that pain on exertion was negatively affected by a lower caseload <25 [OR 1.191 (1.062-1.337); p = 0.003]. While here, too, the difference was small, the fact that in that group there was a greater proportion of patients with small hernia defect sizes may have also played a role since the risk in that group was higher. In this analysis, no evidence was found that pain at rest [OR 1.052 (0.903-1.226); p = 0.516] or chronic pain requiring treatment [OR 1.108 (0.903-1.361); p = 0.326] were influenced by the surgeon volume. As confirmed by previously published studies, the data in the Herniamed Registry also demonstrated that the endoscopic/laparoscopic inguinal hernia surgery caseload impacted the outcome. However, given the overall high-quality level the differences between a "low-volume" surgeon and a "high-volume" surgeon were small. That was due to the use of a standardized technique, structured training as well as continuous supervision of trainees and surgeons with low annual caseload.
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Affiliation(s)
| | - R. Bittner
- Winghofer Medicum Hernia Center, Winghofer Straße 42, 72108 Rottenburg am Neckar, Germany
| | - B. Kraft
- Diakonie Hospital, Department of General and Visceral Surgery, Rosenbergstrasse 38, 70176 Stuttgart, Germany
| | - M. Hukauf
- StatConsult GmbH, Halberstädter Straße 40 a, 39112 Magdeburg, Germany
| | - A. Kuthe
- German Red Cross Hospital, Department of General and Visceral Surgery, Lützerodestraße 1, 30161 Hannover, Germany
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Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi A. Linked hospital and primary care database analysis of the impact of short-term complications on recurrence in laparoscopic inguinal hernia repair. Hernia 2017; 21:191-198. [PMID: 28130603 DOI: 10.1007/s10029-017-1575-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/06/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To study the effects of short-term complications on recurrence following laparoscopic inguinal hernia repair using routine data. BACKGROUND Linked primary and secondary care databases can evaluate the quality of inguinal hernia surgery by quantifying short- and long-term outcome together. METHODS Longitudinal analysis of linked primary care (Clinical Practice Research Datalink) and hospital administrative (Hospital Episodes Statistics) databases quantified 30-day complications (wound infection and bleeding) and surgery for recurrence after primary repair performed between 1st April 1997 and 31st March 2012. RESULTS Out of 41,545 primary inguinal hernia repairs, 10.3% (4296/41,545) were laparoscopic. Complications were less frequent following laparoscopic (1.8%, 78/4296) compared with open (3.5%, 1288/37,249) inguinal hernia repair (p < 0.05). Recurrence was more frequent following laparoscopic (3.5%, 84/2541) compared with open (1.2%, 366/31,859) repair (p < 0.05). Time to recurrence was shorter for laparoscopic (26.4 months SD 28.5) compared with open (46.7 months SD 37.6) repair (p < 0.05). Overall, complications were associated with recurrence (3.2%, 44/1366 with complications; 1.7%, 700/40,179 without complications; p < 0.05). Complications did not significantly increase the risk of recurrence in open hernia repair (OR = 1.49; 95% CI 0.97-2.30, p = 0.069). Complications following laparoscopic repair was significantly associated with increased risk of recurrence (OR = 7.86; 95% CI 3.46-17.85, p < 0.05). CONCLUSIONS Complications recorded in linked routine data predicted recurrence following laparoscopic inguinal hernia repair. Focus must, therefore, be placed on achieving good short-term outcome, which is likely to translate to better longer term results using the laparoscopic approach.
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Affiliation(s)
- G Bouras
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - E M Burns
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A M Howell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College, Charing Cross Hospital, 3 Dorset Rise, London, EC4Y 8EN, UK
| | - T Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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Becerra AZ, Aquina CT, Berho M, Boscoe FP, Schymura MJ, Noyes K, Monson JR, Fleming FJ. Surgeon-, pathologist-, and hospital-level variation in suboptimal lymph node examination after colectomy: Compartmentalizing quality improvement strategies. Surgery 2017; 161:1299-1306. [PMID: 28088321 DOI: 10.1016/j.surg.2016.11.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/05/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and to examine if this variation affects 5-year, disease-specific survival. METHODS A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I-III colon cancer from 2004-2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses. RESULTS The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival. CONCLUSION There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.
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Affiliation(s)
- Adan Z Becerra
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mariana Berho
- Department of Laboratory Medicine, Cleveland Clinic Florida, Weston, FL
| | - Francis P Boscoe
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Maria J Schymura
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, Division of Health Services Policy and Practice, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - John R Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, Florida Hospital, Orlando, FL
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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The impact of age on complications, survival, and cause of death following colon cancer surgery. Br J Cancer 2017; 116:389-397. [PMID: 28056465 PMCID: PMC5294480 DOI: 10.1038/bjc.2016.421] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/04/2016] [Accepted: 11/13/2016] [Indexed: 01/29/2023] Open
Abstract
Background: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. Methods: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I–III colon cancer resections (2004–2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65–74, ⩾75), complications, 1-year survival, and cause of death. Results: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65–74: HR=1.59, 95% CI=1.26–2.00; ⩾75: HR=2.57, 95% CI=2.09–3.16; sepsis: HR=2.58, 95% CI=2.13–3.11) and cardiovascular disease-specific death (65–74: HR=3.72, 95% CI=2.29–6.05; ⩾75: HR=7.02, 95% CI=4.44–11.10; sepsis: HR=2.33, 95% CI=1.81–2.99). Conclusions: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.
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Lorenz R, Stechemesser B, Reinpold W, Fortelny R, Mayer F, Schröder W, Köckerling F. Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School. Hernia 2016; 21:153-162. [PMID: 28032227 DOI: 10.1007/s10029-016-1566-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/17/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The increasingly more complex nature of hernia surgery means that training programs for young surgeons must now meet ever more stringent requirements. There is a growing demand for improved structuring and standardization of education and training in hernia surgery. MATERIALS AND METHODS In 2011, the concept of a Hernia School was developed in Germany and has been gradually implemented ever since. That concept comprises the following series of interrelated, tiered course elements: Hernie kompakt (Hernia compact), Hernie konkret (Hernia concrete), and Hernie complex (Hernia complex). All three course elements make provision for structured clinical training based on guest visits to approved hernia centers. The Hernia compact basic course imparts knowledge of anatomy working with fresh cadavers. Hernia surgery procedures can also be conducted using unfixed specimens. Knowledge of abdominal wall ultrasound diagnostics is also imparted and hernia surgery procedures simulated on pelvic trainers. In all three course elements, lectures are delivered by experts across the entire field of hernia surgery using evidence-based practices from the literature. RESULTS To date, eight Hernie kompakt (Hernia compact) courses have been conducted, in each case with up to 55 participants, and with a total of 390 participants. On evaluating the course, over 95% of participants expressed the view that the Hernia compact course content improved hernia surgery training. Following that positive feedback, the more advanced Hernie konkret (Hernia concrete) and Hernie complex (Hernia complex) course elements were introduced in 2016. CONCLUSION The experiences gained to date since the introduction of a Hernia School-a standardized curriculum concept for continuing training in hernia surgery-has been evaluated by participants as an improvement on hitherto hernia surgery training.
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Affiliation(s)
- R Lorenz
- 3 + Surgeons, Klosterstrasse 34/35, 13581, Berlin, Germany.
| | - B Stechemesser
- Hernia Center Cologne, PAN-Hospital, Zeppelinstrasse 1, 50667, Cologne, Germany
| | - W Reinpold
- Department of Surgery and Hernia Center, Wilhelmsburg Hospital Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - R Fortelny
- Department of General-, Visceral- and Oncologic Surgery, Wilhelminen Hospital, Montleartstrasse 37, 1160, Vienna, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - W Schröder
- Professional Association of German Surgeons, BDC-Academy, Langenbeck-Virchow-Haus, Luisenstraße 58/59, 10117, Berlin, Germany
| | - F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
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Aquina CT, Probst CP, Becerra AZ, Hensley BJ, Iannuzzi JC, Noyes K, Monson JR, Fleming FJ. The impact of surgeon volume on colostomy reversal outcomes after Hartmann's procedure for diverticulitis. Surgery 2016; 160:1309-1317. [DOI: 10.1016/j.surg.2016.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/20/2016] [Accepted: 05/11/2016] [Indexed: 12/22/2022]
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Xu Z, Mohile SG, Tejani MA, Becerra AZ, Probst CP, Aquina CT, Hensley BJ, Arsalanizadeh R, Noyes K, Monson JR, Fleming FJ. Poor compliance with adjuvant chemotherapy use associated with poorer survival in patients with rectal cancer: An NCDB analysis. Cancer 2016; 123:52-61. [DOI: 10.1002/cncr.30261] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/14/2016] [Accepted: 07/06/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Zhaomin Xu
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Supriya Gupta Mohile
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Mohamedtaki Abdulaziz Tejani
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Adan Z. Becerra
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Christian P. Probst
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | | | - Bradley J. Hensley
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Reza Arsalanizadeh
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Katia Noyes
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - John R.T. Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group; University of Central Florida College of Medicine; Orlando Florida
| | - Fergal J. Fleming
- Department of Surgery; University of Rochester Medical Center; Rochester New York
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Abstract
BACKGROUND Hospital readmissions remain a major medical and financial concern to the healthcare system and have become an area of interest in health outcomes performance metrics. There is a pressing need to identify process measures that may help reduce readmissions. OBJECTIVE Our aim was to assess the patient characteristics and surgical factors associated with 30-day readmissions for colorectal surgery in Upstate New York. DESIGN This was a retrospective cohort study. SETTINGS The study included colectomy cases abstracted for the National Surgical Quality Improvement Program in the Upstate New York Surgical Quality Initiative from June 2013 to June 2014. PATIENTS The study consists of 630 colectomies. Patients with a length of stay >30 days or who died during the index admission were excluded. MAIN OUTCOME MEASURES Readmission within 30 days of surgery was the main outcome measure. RESULTS Of 630 colectomy patients, 76 patients (12%) were readmitted within 30 days of surgery. Major and minor complications were associated with 30-day postoperative readmission (OR = 2.99 (95% CI, 1.70-5.28) and OR = 2.19 (95% CI, 1.09-4.43)) but excluded from final analysis because they included both predischarge and postdischarge complications. Risk factors independently associated with 30-day postoperative readmission included diabetes mellitus (OR = 1.94 (95% CI, 1.02-3.67)), smoker within the past year (OR = 2.01 (95% CI, 1.12-3.60)), no scheduled follow-up (OR = 2.20 (95% CI, 1.25-3.86)), and ileostomy formation (OR = 1.97 (95% CI, 1.03-3.77)). LIMITATIONS Limitations include the retrospective design and only 30 days of postoperative follow-up. CONCLUSIONS Consistent with national trends, 1 in 8 patients in the Upstate New York Surgical Quality Initiative program was readmitted within 30 days after colorectal surgery. This study identified several risk factors that may act as tangible targets for intervention, including preoperative smoking cessation programs, optimization of diabetic management, mandatory scheduled follow-up appointments on discharge, and ostomy care pathways.
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Abstract
BACKGROUND Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects. OBJECTIVE The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications DESIGN This was a retrospective cohort study. SETTINGS The study included elective colorectal resections in New York State from 2001 to 2013. PATIENTS The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded. MAIN OUTCOME MEASURES Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured. RESULTS The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92-3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14-2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41-3.07)), and sepsis (OR = 4.51 (95% CI, 4.11-4.94)). LIMITATIONS Limitations include the retrospective design and the possibility of miscoding within administrative data. CONCLUSIONS Large surgeon- and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.
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Aquina CT, Probst CP, Becerra AZ, Hensley BJ, Iannuzzi JC, Noyes K, Monson JRT, Fleming FJ. High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection. Dis Colon Rectum 2016; 59:323-31. [PMID: 26953991 DOI: 10.1097/dcr.0000000000000539] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hospital-acquired Clostridium difficile infection is associated with adverse patient outcomes and high medical costs. The incidence and severity of C. difficile has been rising in both medical and surgical patients. OBJECTIVE Our aim was to assess risk factors and variation associated with the development of nosocomial C. difficile colitis among patients undergoing colorectal resection. DESIGN This was a retrospective cohort study. SETTINGS The study included segmental colectomy and proctectomy cases in New York State from 2005 to 2013. PATIENTS The study cohort included 150,878 colorectal resections. Patients with a documented previous history of C. difficile infection or residence outside of New York State were excluded. MAIN OUTCOME MEASURES A diagnosis of C. difficile colitis either during the index hospital stay or on readmission within 30 days was the main measure. RESULTS C. difficile colitis occurred in 3323 patients (2.2%). Unadjusted C. difficile colitis rates ranged from 0% to 11.3% among surgeons and 0% to 6.8% among hospitals. After controlling for patient, surgeon, and hospital characteristics using mixed-effects multivariable analysis, significant unexplained variation in C. difficile rates remained present across hospitals but not surgeons. Patient factors explained only 24% of the total hospital-level variation, and known surgeon and hospital-level characteristics explained an additional 8% of the total hospital-level variation. Therefore, ≈70% of the hospital variation in C. difficile infection rates remained unexplained by captured patient, surgeon, and hospital factors. Furthermore, there was an ≈5-fold difference in adjusted C. difficile rates across hospitals. LIMITATIONS A limited set of hospital and surgeon characteristics was available. CONCLUSIONS Colorectal surgery patients appear to be at high risk for C. difficile infection, and alarming variation in nosocomial C. difficile infection rates currently exists among hospitals after colorectal resection. Given the high morbidity and cost associated with C. difficile colitis, adopting institutional quality improvement programs and maintaining strict prevention strategies are of the utmost importance.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
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Reply to: “Groin hernia repair, surgeon volume and patient reported outcome measures (PROMs)”. Surgery 2016; 159:980. [DOI: 10.1016/j.surg.2015.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/20/2015] [Indexed: 11/22/2022]
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