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Goldberg D, Sharpe J, Bakillah E, Landau S, Syvyk S, Wirtalla C, Kelz R. Trends in general surgeon operative practice patterns in a modern cohort. Am J Surg 2025; 239:116017. [PMID: 39500007 DOI: 10.1016/j.amjsurg.2024.116017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 09/11/2024] [Accepted: 10/11/2024] [Indexed: 12/17/2024]
Abstract
INTRODUCTION Analyzing general surgeons' operative case mix can provide an update on contemporary practice patterns and inform pragmatic residency training. METHODS We performed a retrospective cohort study of general surgeons in Florida, Iowa, and Maryland, 2016-2020. Cases were identified using billing codes. The Cochran-Armitage test of trends was used to evaluate the proportion of practice devoted to specific case types and operative setting over time. RESULTS General surgeons (n = 1300) performed 1,287,745 cases. The mean (±SD) annual volume per surgeon for all procedures was 356 (±250), with 198 (±152) general surgery operations, 57 (±142) endoscopic procedures, and 101 (±109) other cases. On average, surgeons operated on 7.1 (±2.6) different organ systems. Trends toward a lower proportion of general surgery operations, and a greater proportion of subspecialty procedures and surgery in the outpatient setting over time were demonstrated (p < 0.001). CONCLUSION The practice pattern of the general surgeon continues to be heterogeneous, reflecting the persistent need for a broad training paradigm that permits specialization.
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Affiliation(s)
- Drew Goldberg
- Center for Surgery and Health Economics, University of Pennsylvania, USA; Department of Surgery, Hospital of the University of Pennsylvania, USA.
| | - James Sharpe
- Center for Surgery and Health Economics, University of Pennsylvania, USA
| | - Emna Bakillah
- Center for Surgery and Health Economics, University of Pennsylvania, USA; Department of Surgery, Hospital of the University of Pennsylvania, USA
| | - Sarah Landau
- Center for Surgery and Health Economics, University of Pennsylvania, USA; Department of Surgery, Hospital of the University of Pennsylvania, USA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, University of Pennsylvania, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, USA
| | - Rachel Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, USA; Department of Surgery, Hospital of the University of Pennsylvania, USA
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Orsini A, Lasorsa F, Bignante G, Marchioni M, Schips L, Lucarelli G, Porpiglia F, Kaouk JH, Crivellaro S, Autorino R. Outpatient Robotic Urological Surgery: An Evidence-based Analysis. Eur Urol Focus 2024:S2405-4569(24)00190-1. [PMID: 39428334 DOI: 10.1016/j.euf.2024.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/12/2024] [Accepted: 10/11/2024] [Indexed: 10/22/2024]
Abstract
BACKGROUND AND OBJECTIVE One of the primary advantages of minimally invasive surgery is the shorter hospitalization time, which can potentially allow "outpatient" (OP) procedures. The recent advent of single-port (SP) robotics has further fueled the debate on this topic. We sought to provide an evidence-based analysis of the safety, feasibility, and advantages of robotic urological surgery in the OP setting. METHODS A literature search in PubMed was conducted in June 2024 to identify studies on the feasibility and safety of OP robotic urological surgery. Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and the Population, Intervention, Comparator, Outcome model were used to select retrospective and prospective studies. Data collected included patient characteristics, operative outcomes, same-day discharge (SDD), and complication and readmission rates. Study quality was assessed using the Newcastle-Ottawa Scale. Data analysis and synthesis were performed using Review Manager and GraphPad Prism. KEY FINDINGS AND LIMITATIONS For 3291 patients in noncomparative studies, we found SDD rates of 46.17% for multiport (MP) robot-assisted radical prostatectomy (RARP), 77.35% for SP-RARP, 93.1% for robot-assisted radical or partial nephrectomy, and 93.3% for adrenalectomy. Among comparative studies involving 4130 patients, we found that the OP setting is feasible and safe. Comparison of overall complications between OP and inpatients (IP) settings revealed a relative risk (RR) of 0.66 (95% confidence interval [CI] 0.48-0.91; p = 0.01) favoring OP. The risk of readmission was lower risk for OP than for IP surgery (RR 0.53, 95% CI 0.33-0.85; p = 0.008). Comparison of MP-RARP and SP-RARP revealed that OP protocols are more easily achievable with SP-RARP (44.20% vs 79.59%; p < 0.001). CONCLUSIONS AND CLINICAL IMPLICATIONS OP robotic urological surgery is feasible and safe in selected patients and can enhance satisfaction and reduce costs. SP robotics could promote wider adoption of SDD protocols. Strict case selection minimizes complications. Differences in health care systems should be considered in future evaluations. PATIENT SUMMARY We examined the feasibility and safety of same-day hospital discharge after robot-assisted surgery for urology operations. We found that this option can be safely offered and may be even more viable if the use of robots allowing surgery through a single keyhole incision becomes more widespread.
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Affiliation(s)
- Angelo Orsini
- Department of Urology, Rush University, Chicago, IL, USA; Department of Urology, D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Francesco Lasorsa
- Department of Urology, Rush University, Chicago, IL, USA; Department of Precision and Regenerative Medicine and Ionian Area Urology, Andrology and Kidney Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Gabriele Bignante
- Department of Urology, Rush University, Chicago, IL, USA; Division of Urology, Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Michele Marchioni
- Department of Urology, D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Luigi Schips
- Department of Urology, D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Giuseppe Lucarelli
- Department of Precision and Regenerative Medicine and Ionian Area Urology, Andrology and Kidney Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Jihad H Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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Milluy M, Klein C, Capon G, Bernhard JC, Bladou F, Haissaguerre M, Cremer A, Doublet J, Robert G, Alezra E. Feasibility of outpatient laparoscopic adrenalectomy for primary aldosteronism. THE FRENCH JOURNAL OF UROLOGY 2024; 35:102752. [PMID: 39341461 DOI: 10.1016/j.fjurol.2024.102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 09/18/2024] [Accepted: 09/24/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVE Laparoscopic adrenalectomy (LA) has emerged as the gold standard for the management of adrenal diseases. Despite its low complication rate, the utilization of LA in outpatient settings remains limited. This study explored the feasibility of outpatient LA for primary aldosteronism (PA). DESIGN AND METHODS A retrospective analysis was conducted by reviewing the medical records of consecutive LA procedures performed for PA in our department from 2013 to 2021. A successful outpatient procedure was defined as same-day discharge, less than 12hours after admission, with no readmission within 48hours. A postoperative day one (D1) follow-up call by a nurse assessed complications, pain, and patient satisfaction (Numeric Rating Scale [0-10]). Follow-up visits were scheduled at one, three, and six months. RESULTS During the study period, 76 LAs were performed for PA, with 60 (78.9%) being outpatient procedures. Sixteen patients (21.9%) were not selected for outpatient procedures. The main reasons for contraindicating outpatient procedures were anesthetic or social issues. The success rate of the outpatient procedures was 95% (57/60), with no reported surgical complications. Prolonged hospitalization occurred due to medical reasons such as pain or vomiting. There were no readmissions within 48hours after discharge. The mean pain and patient satisfaction, evaluated at D1, were 2.1/10 and 9.4/10, respectively. At 6 months, 32 patients (59.2%) were cured without any antihypertensive drugs, and 15 (27.8%) were improved (reduction of their antihypertensive treatment). CONCLUSION Outpatient LA for PA has demonstrated feasibility with a high success rate, no readmissions, low postoperative pain, and a high level of patient satisfaction. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Marie Milluy
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France.
| | - Clément Klein
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Grégoire Capon
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Jean-Christophe Bernhard
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Frank Bladou
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Magali Haissaguerre
- Department of Endocrinology, Bordeaux Haut Levesque University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Antoine Cremer
- Department of Cardiology, Bordeaux Saint-André University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Julien Doublet
- Department of Cardiology, Bordeaux Saint-André University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Grégoire Robert
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
| | - Eric Alezra
- Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France; University of Bordeaux, Bordeaux, France
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4
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Green RL, Gao TP, Kuo LE. Perioperative Outcomes After Adrenalectomy for Secondary Adrenal Malignancy. J Surg Res 2024; 296:556-562. [PMID: 38340489 DOI: 10.1016/j.jss.2024.01.029] [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: 11/02/2023] [Revised: 01/06/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling. METHODS The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed. RESULTS Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64). CONCLUSIONS Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately.
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Affiliation(s)
- Rebecca L Green
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
| | - Terry P Gao
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Lindsay E Kuo
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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5
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Xue Y, Xiaoyan L, Yanghao T, Kang W, Jiwen S. Patient satisfaction analysis of robot-assisted minimally invasive adrenalectomy: a single-center retrospective study. J Robot Surg 2024; 18:39. [PMID: 38231274 DOI: 10.1007/s11701-023-01755-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/14/2023] [Indexed: 01/18/2024]
Abstract
The objective of this study is to compare the satisfaction of patients undergoing robot-assisted retroperitoneal laparoscopy adrenalectomy under the ambulatory mode and conventional mode. Basic information and clinical data of patients who underwent robotic-assisted posterior laparoscopic adrenalectomy between June 2020 and June 2023 were queried from our case system. The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®) was used to investigate patient satisfaction with preoperative preparation, discharge counseling, postoperative instructions, postoperative pain, and satisfaction with nursing work. The stats R package was used to select the appropriate statistic for the statistics based on the characteristics of the data. A total of 311 patients who underwent robot-assisted posterior laparoscopic adrenalectomy were enrolled in our case system. There were no statistical differences between the two groups in gender, age, body mass index, ASA classification, laterality, maximum tumor diameter, type of resection, hormonal activity, disease type, pathological classification, duration of surgery, estimated intraoperative bleeding, postoperative complications and follow-up period that were compared between the two groups of patients. There were no significant differences in preoperative preparation score, discharge counseling score, postoperative guidance score and nursing care satisfaction score (P > 0.05). Postoperative hospitalization, peristalsis time, defecation time, time to first postoperative mobilization, duration of indwelling drain and hospitalization costs in patients in the ambulatory model group were significantly less than patients in the conventional model group (P < 0.001). Patients in the ambulatory model group had significantly higher postoperative pain relief scores than patients in the conventional model group. In conclusion, our data suggest that patient satisfaction is equal between the conventional and ambulatory mode of performing robotic-assisted adrenalectomy. Patient satisfaction was probably associated with shorter hospitalization days, adequate preoperative preparation and standardized, high-quality post-discharge information and guidance.
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Affiliation(s)
- Yao Xue
- Department of Ambulatory Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Luo Xiaoyan
- Department of Ambulatory Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Tai Yanghao
- Department of Ambulatory Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Wang Kang
- Department of Ambulatory Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Shang Jiwen
- Department of Ambulatory Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
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Hendrick LE, Fleming AM, Dickson PV, DeLozier OM. Same day discharge after minimally invasive adrenalectomy: a national study. Surg Endosc 2023; 37:8316-8325. [PMID: 37679582 DOI: 10.1007/s00464-023-10355-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA. METHODS Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling. RESULTS Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020. CONCLUSIONS Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.
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Affiliation(s)
- Leah E Hendrick
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Olivia M DeLozier
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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7
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Green RL, Gao TP, Hamilton AE, Kuo LE. Older age impacts outcomes after adrenalectomy. Surgery 2023; 174:819-827. [PMID: 37460336 DOI: 10.1016/j.surg.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/21/2023] [Accepted: 06/18/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups. METHODS The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed. RESULTS Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60. CONCLUSION Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population.
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Affiliation(s)
- Rebecca L Green
- Department of Surgery, Temple University Hospital, Philadelphia, PA.
| | - Terry P Gao
- Department of Surgery, Temple University Hospital, Philadelphia, PA. https://twitter.com/terrypgao
| | - Audrey E Hamilton
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA. https://twitter.com/AudreyHamilton
| | - Lindsay E Kuo
- Department of Surgery, Temple University Hospital, Philadelphia, PA. https://twitter.com/lindsaykuo
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Conzo G, Patrone R, Flagiello L, Catauro A, Conzo A, Cacciatore C, Mongardini FM, Cozzolino G, Esposito R, Pasquali D, Bellastella G, Esposito K, Docimo L. Impact of Current Technology in Laparoscopic Adrenalectomy: 20 Years of Experience in the Treatment of 254 Consecutive Clinical Cases. J Clin Med 2023; 12:4384. [PMID: 37445419 DOI: 10.3390/jcm12134384] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA), which avoids large abdomen incisions, is considered the gold standard technique for the treatment of benign small- and medium-size adrenal masses (<6 cm) and weighing < 100 g. A trascurable mortality and morbidity rate, short hospitalization and patient rapid recovery are the main advantages compared to traditional surgery. During the past decade, a new surgical technology has been developed that expedites a "clipless" adrenalectomy. Here, the authors analyze a clinical series of 254 consecutive patients who were affected by adrenal gland neoplasms and underwent LA by the transabdominal lateral approach over the two last decades. A literature review is also presented. METHODS Preoperative, intraoperative and postoperative data from 254 patients who underwent LA between January 2003 and December 2022 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in the case of pheochromocytoma (PCC) while spironolactone and potassium were employed to treat Conn's disease. The same surgeon (CG) performed all the LA and utilized the same laparoscopic transabdominal lateral approach. Different dissection tools-ultrasonic, bipolar or mixed scissors-and hemostatic agents were used during this period. The following results were obtained: 254 patients were included in the study; functioning tumors were diagnosed in 155 patients, 52 patients were affected by PCCs, 55 by Conn's disease, 48 by Cushing's disease. Surgery mean operative time was 137.33 min (range 100-180 min) during the learning curve adrenalectomies and 98.5 min (range 70-180) in subsequent procedures. Mean blood loss was respectively 160.2 mL (range 60-280) and 96.98 mL (range 50-280) in the first 30 procedures and the subsequent ones. Only three conversions (1.18%) to open surgery occurred. No mortality or postoperative major complications were observed, while minor complications occurred in 19 patients (3.54%). In 153 out of 155 functioning neoplasms, LA was effective in the normalization of the endocrine profile. According to our experience, a learning curve consisting of 30 cases was identified. In fact, a lower operative time and a lower complication rate was reported following 30 LA. CONCLUSIONS LA is a safe procedure, even for masses larger than 6 cm and PCCs. Undoubtedly, the development of surgical technology has made it possible reducing operative times, performing a "clipless" adrenalectomy and extending the indications in the treatment of more complex patients. A multidisciplinary team, in referral high-volume centers, is recommended in the management of adrenal pathology. A 30-procedure learning curve is necessary to improve surgical outcomes.
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Affiliation(s)
- Giovanni Conzo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Renato Patrone
- Dieti Department, University of Naples Federico II, 80100 Naples, Italy
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Luigi Flagiello
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Antonio Catauro
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Alessandra Conzo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Chiara Cacciatore
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Giovanni Cozzolino
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Rosetta Esposito
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Daniela Pasquali
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", 80100 Naples, Italy
| | - Giuseppe Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, 80138 Naples, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, 80138 Naples, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, Department of Traslational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
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Price G, Fazendin J, Porterfield JR, Chen H, Lindeman B. Association Between Surgical Indication and Outcomes for Outpatient Adrenalectomy. J Surg Res 2023; 284:296-302. [PMID: 36628915 DOI: 10.1016/j.jss.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Despite a favorable risk-benefit profile, inpatient admission postoperatively for minimally invasive adrenalectomy (MIA) has remained common. Prior studies have shown that outpatient MIA was not associated with an increased 30-day complications or readmission. However, this has not been explored in-depth by adrenalectomy indication. We aimed to examine whether the safety profile of outpatient MIA varies by adrenal indication. MATERIALS AND METHODS Clinicopathologic parameters were examined for all MIAs entered into an adrenal database at our institution from 2012 to 2021. Predictor variables included patient demographics, surgical indication, and operative time. Outcomes were 30-day emergency department visit, readmission, and complication rates between surgical indications, comparing outpatient and inpatient groups. Statistical analyses were performed using Kruskal-Wallis, Wilcoxon, Mann-Whitney, and Chi-squared tests, as appropriate. RESULTS A total of 185 MIA patients were included. Outpatient MIA was performed in 53 patients (28.6%). Outpatient discharge post-MIA was related to both surgical indication and operative time. Pheochromocytoma (PC) patients were less likely to be discharged as an outpatient postoperatively when compared to all other indications (13.0% versus 33.8%, P = 0.007). Among all patients with operations 2-3 h in length, PC patients were less likely to be discharged home as an outpatient (10% versus 33.3%, P = 0.040). No significant differences were identified between outpatient and inpatient MIA groups for complications, emergency department visits, or readmission (P > 0.05 for all). Only six outpatient MIA patients had any complication (11.3%) and six were readmitted (11.3%). CONCLUSIONS Outpatient MIA was demonstrated to be associated with similar, low complication and readmission rates compared to inpatient MIA, although it was used less often for patients with PC or prolonged operative times. Our study highlights potential evidence that outpatient MIA can be safely used in selected patients across all indications for adrenal surgery.
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Affiliation(s)
- Griffin Price
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John R Porterfield
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
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Shariq OA, Bews KA, Etzioni DA, Kendrick ML, Habermann EB, Thiels CA. Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e231198. [PMID: 36862412 PMCID: PMC9982689 DOI: 10.1001/jamanetworkopen.2023.1198] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
IMPORTANCE The American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic. OBJECTIVE To investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures. DESIGN, SETTING, AND PARTICIPANTS This multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery. RESULTS A total of 988 436 patients were identified (mean [SD] age, 54.5 [16.1] years; 574 683 women [58.1%]), of whom 823 746 underwent scheduled surgery before COVID-19 and 164 690 had surgery during COVID-19. On multivariable analysis, the odds of outpatient surgery during COVID-19 (vs 2019) were higher in patients who underwent mastectomy for cancer (odds ratio [OR], 2.49 [95% CI, 2.33-2.67]), minimally invasive adrenalectomy (OR, 1.93 [95% CI, 1.34-2.77]), thyroid lobectomy (OR, 1.43 [95% CI, 1.32-1.54]), breast lumpectomy (OR, 1.34 [95% CI, 1.23-1.46]), minimally invasive ventral hernia repair (OR, 1.21 [95% CI, 1.15-1.27]), minimally invasive sleeve gastrectomy (OR, 2.56 [95% CI, 1.89-3.48]), parathyroidectomy (OR, 1.24 [95% CI, 1.14-1.34]), and total thyroidectomy (OR, 1.53 [95% CI, 1.42-1.65]). These odds were all greater than those observed for 2019 vs 2018, 2018 vs 2017, and 2017 vs 2016, suggesting that an accelerated increase in outpatient surgery rates in 2020 occurred as a consequence of COVID-19, rather than a continuation of secular trends. Despite these findings, only 4 procedures had a clinically meaningful (≥10%) overall increase in outpatient surgery rates during the study period: mastectomy for cancer (+19.4%), thyroid lobectomy (+14.7%), minimally invasive ventral hernia repair (+10.6%), and parathyroidectomy (+10.0%). CONCLUSIONS AND RELEVANCE In this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.
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Affiliation(s)
| | - Katherine A. Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Elizabeth B. Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Unilateral Adrenalectomy for Primary Aldosteronism Due to Bilateral Adrenal Disease Can Result in Resolution of Hypokalemia and Amelioration of Hypertension. World J Surg 2023; 47:314-318. [PMID: 36207420 DOI: 10.1007/s00268-022-06780-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Bilateral idiopathic hyperaldosteronism (IHA) is responsible for 60% of primary aldosteronism (PA) cases. Medical management is standard of care for IHA. Unilateral adrenalectomy (UA) with the intent of debulking total aldosterone production as a palliative measure remains controversial. METHODS Single-center retrospective review (2010-2020) of patients undergoing UA with a diagnosis of PA due to IHA (lateralization index [LI] on adrenal venous sampling [AVS] < 4). Demographic, pre-operative, intra-operative, and post-operative variables were assessed. Hypertensive regimens were converted to the WHO Defined Daily Dose (DDD). RESULTS Twenty-four patients were identified, 14, 58% male and mean age 52 ± 10 years. Preoperative hypokalemia was present in 22, 92% of patients. Median number of antihypertensives taken was 3 (interquartile range [IQR], 2-4) and median DDD was 4 (IQR, 3-5.3). Median lateralization index on AVS was 3.52 (range, 1.19-3.88). All operations were performed in minimally invasive fashion. There were no conversions to open procedure, ICU admissions, or post-operative complications. Median follow-up was 10.5 months (range, 1-145 months). Hypokalemia resolved in 17, 76% of patients at last follow-up. Post-operative median number of antihypertensives taken was 1 (IQR, 1-3) and median DDD was 2 (IQR, 0.5-2.75) from 4, P = 0.003. Three (%) patients required continuation of mineralocorticoid receptor antagonists post-operatively. Blood pressure control improved in 65% of patients. CONCLUSION Unilateral adrenalectomy in the setting of bilateral hyperaldosteronism can improve blood pressure control and stabilize potassium levels in selected patients. Further prospective studies in larger cohorts will be necessary to further define the role of unilateral adrenalectomy in the setting of PA due to bilateral adrenal disease.
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McKenna NP, Glasgow AE, Shariq OA, Larson DW, Ghanem OM, McKenzie TJ, Habermann EB. Challenging Surgical Dogma: Are Routine Postoperative Day 1 Labs Necessary after Bariatric Operations? Surg Obes Relat Dis 2022; 18:1261-1268. [DOI: 10.1016/j.soard.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
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Ravivarapu KT, Garden E, Chin CP, Levy M, Al-Alao O, Sewell-Araya J, Small A, Mehrazin R, Palese M. Same-day discharge following minimally invasive partial and radical nephrectomy: a National Surgical Quality Improvement Program (NSQIP) analysis. World J Urol 2022; 40:2473-2479. [PMID: 35907008 DOI: 10.1007/s00345-022-04105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/11/2022] [Indexed: 10/16/2022] Open
Abstract
PURPOSE Minimally invasive partial nephrectomy (MIPN) and radical nephrectomy (MIRN) have successfully resulted in shorter length of stay (LOS) for patients. Using a national cohort, we compared 30-day outcomes of SDD (LOS = 0) versus standard-length discharge (SLD, LOS = 1-3) for MIRN and MIPN. METHODS All patients who underwent MIPN (CPT 50,543) or MIRN (CPT 50,545) in the ACS-NSQIP database from 2012 to 2019 were reviewed. SDD and SLD groups were matched 1:1 by age, sex, race, body mass index, American Society of Anesthesiologists score, and medical comorbidities. We compared baseline characteristics, 30-day Clavien-Dindo (CD) complications, reoperations, and readmissions between SDD and SLD groups. Multivariable logistic regressions were used to evaluate predictors of adverse outcomes. RESULTS 28,140 minimally invasive nephrectomy patients were included (SDD n = 237 [0.8%], SLD n = 27,903 [99.2%]). There were no significant differences in 30-day readmissions, CD I/II, CDIII, or CD IV complications before and after matching SDD and SLD groups. On multivariate regression analysis, SDD did not confer increased risk of 30-day complications or readmissions for both MIPN and MIRN. CONCLUSION SDD after MIPN and MIRN did not confer increased risk of postoperative complications, reoperation, or readmission compared to SLD. Further research should explore optimal patient selection to ensure safe expansion of this initiative.
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Affiliation(s)
- Krishna Teja Ravivarapu
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Evan Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Chih Peng Chin
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Micah Levy
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Osama Al-Alao
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Joseph Sewell-Araya
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Alexander Small
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA
| | - Michael Palese
- Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1272, New York, NY, 10029, USA.
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Garden EB, Ravivarapu KT, Levy M, Chin CP, Omidele O, Tomer N, Al-Alao O, Araya JS, Small AC, Palese MA. The utilization and safety of same-day discharge after transurethral benign prostatic hyperplasia surgery: a case-control, matched analysis of a national cohort. Urology 2022; 165:59-66. [DOI: 10.1016/j.urology.2022.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/20/2022] [Accepted: 01/26/2022] [Indexed: 12/21/2022]
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Shariq OA, McKenzie TJ. Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment. Ther Adv Chronic Dis 2021; 12:20406223211033103. [PMID: 34349894 PMCID: PMC8295938 DOI: 10.1177/20406223211033103] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.
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Affiliation(s)
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
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Rahbari R, Alavi M, Alvarez JF, Perez CA, Tedesco MM, Brill E, Park JJ, Svahn J, Yutan EU, Martinez AG, Zhou M, Philipp SR, Herrinton LJ. Volume Matters: Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery. Ann Surg Oncol 2021; 28:8849-8860. [PMID: 34142292 DOI: 10.1245/s10434-021-10297-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/27/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. METHODS In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. RESULTS In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. CONCLUSIONS Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.
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Affiliation(s)
- Reza Rahbari
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Mubarika Alavi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Juan F Alvarez
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Carlos A Perez
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Maureen M Tedesco
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Elliot Brill
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Judith J Park
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jonathan Svahn
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Elaine U Yutan
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Arturo G Martinez
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Minhao Zhou
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Scott R Philipp
- Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
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