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Dixon PR, Moshtaghi O, Khan U, Harris JP, Schwartz MS, Friedman RA. Association Between Facility Surgical Volume and Excess Time in the Hospital After Surgical Resection of Vestibular Schwannomas. JAMA Otolaryngol Head Neck Surg 2023; 149:352-358. [PMID: 36862385 PMCID: PMC9982737 DOI: 10.1001/jamaoto.2022.5243] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/02/2023] [Indexed: 03/03/2023]
Abstract
Importance High surgical vestibular schwannoma case volume in a medical institution may decrease the risk of adverse outcomes among patients undergoing vestibular schwannoma surgery. Objective To study the association between surgical vestibular schwannoma case volume and excess time in the hospital after vestibular schwannoma surgery. Design, Setting, and Participants This cohort study evaluated data from the National Cancer Database from January 1, 2004, through December 31, 2019, on Commission on Cancer-accredited facilities in the US. The hospital-based sample comprised adult patients aged 18 years or older with a vestibular schwannoma treated with surgery. Exposures Facility case volume, defined as the mean number of surgical vestibular schwannoma cases per year in the 2 years preceding the index case. Main Outcomes and Measures The primary outcome was a composite of prolonged hospital stay (>90th percentile) or 30-day readmission. Risk-adjusted restricted cubic splines were used to model the probability of the outcome according to facility volume. The inflection point (in cases per year) when the declining risk of excess time in the hospital began to plateau was selected as the threshold to define high- and low-volume facilities. Outcomes were compared among patients treated at high- and low-volume facilities, with mixed-effects logistic regression models adjusting for patient sociodemographic characteristics, comorbidities, tumor size, and clustering within facilities. Collected data were analyzed between June 24 and August 31, 2022. Results Among 11 524 eligible patients (mean [SD] age, 50.2 [12.8] years; 53.5% female; 46.5% male) who underwent surgical resection of vestibular schwannoma at 66 reporting facilities, the median length of stay was 4 (IQR, 3-5) days, and 655 patients (5.7%) were readmitted within 30 days. The median case volume was 16 (IQR, 9-26) cases per year. An adjusted restricted cubic spline model identified a downtrending probability of excess time in the hospital with increasing volume. The declining risk of excess time in the hospital began to plateau at a facility volume of 25 cases per year. Surgery at a facility with an annual case volume at or above this threshold was independently associated with a 42% reduction in the odds of excess time in the hospital compared with surgery at a low-volume center (odds ratio, 0.58; 95% CI, 0.44-0.77). Conclusions and Relevance This cohort study found that among adults undergoing vestibular schwannoma surgery, a higher facility case volume was associated with a reduced risk of prolonged hospital stay or 30-day readmission. A facility case volume of 25 cases per year may represent a risk-defining threshold.
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Affiliation(s)
- Peter R. Dixon
- Department of Otolaryngology–Head & Neck Surgery, University of California San Diego, San Diego
| | - Omid Moshtaghi
- Department of Otolaryngology–Head & Neck Surgery, University of California San Diego, San Diego
| | - Usman Khan
- Department of Neurological Surgery, University of California San Diego, San Diego
| | - Jeffrey P. Harris
- Department of Otolaryngology–Head & Neck Surgery, University of California San Diego, San Diego
| | - Marc S. Schwartz
- Department of Neurological Surgery, University of California San Diego, San Diego
| | - Rick A. Friedman
- Department of Otolaryngology–Head & Neck Surgery, University of California San Diego, San Diego
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Lee WJ, Choi JW, Kong DS, Nam DH, Lee JI, Seol HJ. Factors Associated with Acute Obstructive Hydrocephalus After Retrosigmoid Approach for Extra-Axial Cerebellopontine Angle Tumors. World Neurosurg 2022; 166:e1-e10. [PMID: 35489600 DOI: 10.1016/j.wneu.2022.04.088] [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: 01/03/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study aimed to identify the risk factors for acute obstructive hydrocephalus (AOHCP) after extra-axial cerebellopontine angle (CPA) tumor surgery using the retrosigmoid (RS) approach. METHODS This retrospective study assessed 154 patients (100 vestibular schwannomas, 34 CPA meningiomas [MNGs], 9 trigeminal schwannomas, and 11 petroclival MNGs) who underwent surgical resection using the RS approach by a single surgeon between August 2010 and September 2019. AOHCP was defined as postoperative ventricular enlargement due to cerebrospinal fluid flow obstruction caused by surgery-related cerebellar injury within 1 week. The radiological characteristics of the tumors were classified, and the surgical outcomes were reviewed. We analyzed the impact of different factors on the development of AOHCP after surgery. RESULTS AOHCP developed in 17 (11%) patients, all of whom were treated with external ventricular drain insertion. Multivariate analysis showed that CPA MNGs (odds ratio [OR], 37.98), grade of tumor extension beyond the petroclival junction (grade 1: OR, 16.42; grade 2: OR, 17.47), major fourth ventricle compression (OR, 17.77), and surgery-related hemorrhage (OR, 7.64) were associated with AOHCP. Surgery-related hemorrhage was observed in 17 (11%) patients. 9 (6%) patients underwent ventriculoperitoneal shunt surgery because of persistent HCP. CONCLUSIONS An increased risk of AOHCP after the RS approach was observed in patients with extra-axial CPA tumors with clival extension and major fourth ventricle compression. Compulsive and meticulous hemostasis must be achieved because postoperative hemorrhage is associated with AOHCP.
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Affiliation(s)
- Won-Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Farag AA, Ibrahim AEKSED, Alaghory IM. Clinical Benefits of Facial Nerve Monitoring during Cerebellopontine Angle Surgery. OPEN JOURNAL OF MODERN NEUROSURGERY 2022; 12:9-27. [DOI: 10.4236/ojmn.2022.121002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Almosnino G, Sikora MJ, Farrokhi FR, Schwartz SR, Zeitler DM. Tumor-Related and Patient-Related Variables Affecting Length of Hospital Stay Following Vestibular Schwannoma Microsurgery. Ann Otol Rhinol Laryngol 2021; 131:535-543. [PMID: 34210194 DOI: 10.1177/00034894211029103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Review a single institution's vestibular schwannoma (VS) microsurgery experience to determine (1) correlations between demographics, comorbidities, and/or surgical approach on hospital length of stay (LOS) and discharge disposition and (2) trends in surgical approach over time. METHODS Retrospective case series from a multidisciplinary skull base program at a tertiary care, academic hospital. All adult (>18 years) patients undergoing primary microsurgery for VS between 2008 and 2018 were included. RESULTS A total of 147 subjects were identified. Surgical approach was split between middle fossa (MF) (16%), retrosigmoid (RS) (35%), and translabyrinthine (TL) (49%) craniotomies. For the 8% of patients had other than routine (OTR) discharge. Mean LOS was significantly longer for patients undergoing RS than either MF or TL. Brainstem compression by the tumor was associated with longer LOS as were diagnoses of chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD). For all discharges, the 40 to 50- and 50 to 60-year-old subgroups had significantly shorter LOS than the 70-years-and-older patients. For the 92% of patients routinely discharged, there was a significantly shorter LOS in the 40 to 50-year-olds compared to the 70-years-and-older patients. There was a significant shift in surgical approach from RS to TL over the study period. CONCLUSION Over 90% of VS microsurgery patients were routinely discharged with a median hospital LOS of 3.2 days, both of which are consistent with published data. There is an inverse relationship between age and LOS with patients older than 70 years having significantly longer LOS. Brainstem compression, COPD, PVD, and the RS approach negatively affect LOS. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Galit Almosnino
- Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Matt J Sikora
- Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Farrokh R Farrokhi
- Department of Neurosurgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Seth R Schwartz
- Listen for Life Center, Department of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, WA 98101, USA
| | - Daniel M Zeitler
- Listen for Life Center, Department of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, WA 98101, USA
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Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning. Otol Neurotol 2021; 42:e584-e592. [PMID: 33443974 DOI: 10.1097/mao.0000000000003042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Patients who underwent vestibular schwannoma resection between 2008 and 2019. INTERVENTIONS Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing. MAIN OUTCOME MEASURES LOS was evaluated as the number of days from surgery to discharge. RESULTS Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59). CONCLUSIONS Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.
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Jun W, Gao YL, Yu HG, Huang QL, Long XQ, Liu GH, Ting X, Zhong XY, Zhou YF. Comparison of translabyrinthine and retrosigmoid approach for treating vestibular schwannoma: A meta-analysis. Clin Neurol Neurosurg 2020; 196:105994. [PMID: 32540713 DOI: 10.1016/j.clineuro.2020.105994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND To date, the literature directly comparing the translabyrinthine approach and retrosigmoid approach in the operation of patients with vestibular schwannoma was limited. We aimed to evaluate postoperative complications between translabyrinthine approach and retrosigmoid approach for treating vestibular schwannoma patients. MATERIAL AND METHOD Potential publications were selected from PubMed, Web of Science and Cochrane Library. Gray relevant studies were manually searched. We set the searching time spanning from the creation date of electronic engines to February 2020. STATA version 12.0 was exerted to process the pooled data. RESULTS A total of 9 literature included in the study, involving 2429 patients, hails from the Germany, USA, Canada, Italy, and France. Of these 2429 patients with vestibular schwannoma, there were 1628 cases from the translabyrinthine approach group versus 801 cases from the retrosigmoid approach group. The results demonstrated that the translabyrinthine approach group was associated with a lower rate of tinnitus (OR = 2.687; 95 %CI, 1.167-6.191; P = 0.02) and cranial nerve deficit (OR = 2.946; 95 %CI, 1.562-5.557; P = 0.001). And the translabyrinthine approach group was associated with a higher total resection rate (OR = 0.246; 95 %CI (0.071-0.848); P = 0.026). However, no statistic differences were found in the incidence of the near total (OR = 0.751; P = 0.351), subtotal resection (OR = 3.664; P = 0.109), postoperative facial nerve dysfunctions (OR, 0.763; P = 0.626), postoperative meningitis (OR = 2.7; P = 0.279), cerebrospinal fluid leak (OR = 1.225; P = 0.777), postoperative headache (OR = 1.412; P = 0.339), ophthalmic complications (OR = 0.87; P = 0.59), and vascular complications (OR = 2.501; P = 0.139). CONCLUSION Based on current evidence, the translabyrinthine approach was associated with a higher rate of total resection and a lower rate of the tinnitus and cranial nerve deficit. But the risk of cranial nerve deficit was clearly affected by the preoperative status. And a translabyrintine approach could imply a complete sensorineural hearing loss, which contribute to the lower rate of postoperative tinnitus. Consequently, more evidence-based researches are needed to supplement this opinion.
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Affiliation(s)
- Wu Jun
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Yun-Long Gao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Hai-Guang Yu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Qing-Liang Huang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Xin-Quan Long
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Guo-Hua Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Xu Ting
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Xiu-Ying Zhong
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
| | - Yu-Fan Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (Fu Zhou First People's Hospital of Jiangxi Province), Fuzhou, Jiangxi, 344000 PR China.
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Clinical outcomes of resecting scarpa's ganglion during vestibular schwannoma surgery. J Clin Neurosci 2020; 76:114-117. [PMID: 32284286 DOI: 10.1016/j.jocn.2020.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/05/2020] [Indexed: 01/06/2023]
Abstract
Vestibular schwannomas are slow-growing tumors arising from the Schwann cells of the vestibular nerve. Scarpa's ganglion, the vestibular nerve ganglion, is located within the internal auditory meatus. Surgical treatment of vestibular schwannomas carries the potential of resecting Scarpa's ganglion along with the tumor. No prior studies have evaluated outcomes based on the presence of Scarpa's ganglion within tumor specimens. The neurosurgery patient records were queried for patients who underwent surgical resection of vestibular schwannomas at the University of Missouri Healthcare between January 1, 2008 and December 31, 2018. Inclusion criteria consisted of minimum age of 18, imaging demonstrating an eighth nerve tumor, surgical resection thereof, and a final pathological diagnosis of WHO grade I schwannoma. Data were collected retrospectively. The histological slides of the tumors were reviewed, and the presence or absence of the ganglion was noted. Outcomes analyzed included postoperative dizziness, hearing, and facial nerve function. Fifty-two patients met inclusion criteria. Ten (19%) resected tumors contained portions of the ganglion. No difference in risk of resection of ganglion occurred based on the surgical approach (p = 0.2454). Mean follow-up duration was 24.6 months ± 26.2 standard deviation. No differences in postoperative hearing or dizziness (p = 0.8483 and p = 0.3190 respectively) were present if Scarpa's ganglion was resected. House-Brackmann classification of facial nerve function at last follow-up was similar (p = 0.9190). Resection of Scarpa's ganglion with vestibular schwannomas does not increase risk of post-operative dizziness, facial nerve weakness, or hearing loss.
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