Monitoring performance in thyroidectomy: cumulative sum analysis of outcomes

Feasibility and safety of pure single-incision laparoscopic total and proximal gastrectomy for early gastric cancer: propensity score-matched comparison to multiport totally laparoscopic approach

BACKGROUND

There have been few studies regarding the feasibility and safety of pure single-incision laparoscopic total gastrectomy (SITG) or proximal gastrectomy (SIPG) for early gastric cancer (EGC). The purpose of this study was to analyze the surgical outcome of all consecutive SITG or SIPG cases compared with multiport laparoscopic total gastrectomy (MLTG) or proximal gastrectomy (MLPG) for EGC.

METHODS

We analyzed all consecutive SITG or SIPG cases with double-tract reconstruction for ECG, including the initial case, between March 2013 and December 2021. SITG/SIPG was performed on patients without significant systemic comorbidities through a 3-4 cm vertical transumbilical incision. SITG/SIPG was matched to multiport laparoscopic total or proximal gastrectomy (MLTG/MLPG) cases performed in the same period using a 1:3 propensity score matching, including sex, body mass index (BMI), age and type of resection, year of operation, and institution as covariates. We compared perioperative clinicopathological characteristics and early postoperative morbidity within 1 month after surgery between the SITG/SIPG and MLTG/MLPG groups.

RESULTS

In total, 21 patients with SITG and 15 patients with SIPG were compared with those with MLTG (n = 264) and MLPG (n = 220). No conversion to an open or multiport approach occurred in the SITG/SIPG group. After matching, operation time was similar between SITG/SIPG and MLTG/MLPG (223.9 ± 63.5 min vs 234.8 ± 68.7 min, P = 0.402). Length of stay was not significantly different between SITG/SIPG and MLTG/MLPG (11.9 ± 15.4 days vs 8.4 ± 5.0 days, P = 0.210). The average number of retrieved lymph nodes was not significantly different between SITG and MLTG (53.1 ± 16.3 vs 63.2 ± 27.5, P = 0.115), but it was significantly higher in SIPG than MLPG (59.6 ± 27.2 vs 46.0 ± 19.7, P = 0.040). The overall complication rate (30.6% vs 25.9%, P = 0.666) and Clavien-Dindo grade III or higher complication rates (13.9% vs 6.5%, P = 0.175) were not significantly different between the SITG/SIPG and MLTG/MLPG groups.

CONCLUSION

Cautious adoption of SITG/SIPG procedures for EGC is feasible and safe.

Prospective cohort study of parathyroid function and quality of life after total thyroidectomy for thyroid cancer: robotic surgery vs. open surgery

OBJECTIVE

To compare robot-assisted thyroidectomy (RT) and open thyroidectomy (OT) through a prospective cohort study focusing on the rate of postoperative hypoparathyroidism, efficacy, and quality of life (QoL).

SUMMARY BACKGROUND DATA

Hypoparathyroidism is a frequent complication after thyroidectomy. Reducing the risk of hypoparathyroidism after total thyroidectomy is a crucial and difficult task for thyroid surgeons.

METHODS

We prospectively enroled 306 patients with papillary thyroid carcinoma into an RT group and OT group. The former used "super-meticulous" capsular dissection) and the latter used traditional meticulous capsular dissection. Patients were evaluated by scales [Short Form (SF)-36, Visual Impairment Scale (VIS), Swallowing Impairment Scale (SIS), Neck Impairment Scale (NIS), Scar questionnaire (SCAR-Q)].

RESULTS

The rates of transient hypoparathyroidism, permanent hypoparathyroidism, and transient hypocalcemia after surgery in the OT group and RT group were significantly different ( P <0.001). SIS and VIS scores in the two groups were significantly different ( P <0.001). SF-36 showed significant differences ( P <0.001) in the subsections of "physiological function", "body pain", "general health", "vitality", "social function", "role emotional", and "mental health" between the two groups. SCAR-Q showed that the length and appearance of scars showed significant differences between the two groups.

CONCLUSIONS

RT with Super-meticulous capsular dissection can protect parathyroid function and improve postoperative QoL, and could be a new option for robot-assisted surgery against thyroid cancer.

How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency

OBJECTIVE

Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed.

METHODS

We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development.

RESULTS

We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives.

CONCLUSIONS

Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.

The CUSUM curve combined with comprehensive complication index for assessing short-term complications of radical cystectomy

Objective

To evaluate the comprehensive complication index(CCI) and Clavien‐Dindo classification(CDC) for short‐term postoperative complications in radical cystectomy and assess cumulative surgical morbidity to compare sufficient surgical skill.

Methods

From September 30, 2010, to October 1, 2020, clinical data of patients with urothelial carcinoma who underwent radical cystectomy with urinary diversion were gathered, patients who had only a urinary diversion, bladder sparing surgery, additional abdominal surgeries at the same time were all excluded. The CDC and CCI were utilized to evaluate 30‐d complications after radical cystectomy and the relevance of hospital stay was compared between CCI and CDC. The cumulative sum control models (CUSUM) were used to evaluate the overall surgical morbidity of radical cystectomy in our facility and for comparisons between surgeons.

Results

This study enrolled a total of 635 individuals, 548 (86.3%) of whom had 1124 problems. The incidence of severe complications (CDC≥ Grade III) was 10.2%. The average CCI was 20.2 ± 14.7. Gender, urinary diversion subtype, procedure method, and surgeon were significantly correlated with the increase of CCI (p < 0.05). The CCI demonstrated a better relationship with hospital stay (R² = 0.429) than the CDC (R² = 0.361). The CUSUM‐CCI model demonstrated a difference and growth distribution in dynamic time between individual surgeons.

Conclusions

CCI can better reflect the incidence of complications for radical cystectomy than CDC, and CCI is more strongly correlated with postoperative hospital stay. The CUSUM‐CCI model can reflect the quality of surgical skill for each surgeon instantaneously.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand

BACKGROUND

Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature.

METHODS

A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance.

RESULTS

There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature.

CONCLUSION

Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Microscopic Thyroidectomy: The Way We Do It

The present study was conducted with an intent to document the reduced morbidity in terms of postoperative hypocalcemia, injury to recurrent laryngeal and external branch of superior laryngeal nerve, in patients undergoing microscope assisted thyroidectomy. The present study enrolled a total of 878 patrients who underwent hemi, total and completion thyroidectomies, over a period of 3 years at Jain ENT Hospital, Jaipur. In the present study, out of 1118 RL nerves dissected temporary paresis was found in 1.52% and permanent palsy in only 0.36%. Temporary hypocalcemia was seen in 8.12% while permanent hypocalcemia in 0.6% patients. EBSLN could be identified in 1082 of the 1118 nerves dissected. We recommend the use microscope routinely for all thyroid surgeries, starting from the very first step in view of the reduced morbidity that it offers.

Safety and Efficacy of Bipolar Radiofrequency Ablation Device in Hemostasis during Thyroidectomy in Comparison with Ultrasonic Scalpel: A Comparative Study

AIM

Ultrasonic scalpel is one of the recent advances in surgical technology. The main limitation of their use is the cost. However, radiofrequency ablation device is a refined type of electrosurgical cautery that can be used with conventional reusable bipolar cautery forceps. This study aims to compare the efficacy of bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps for hemostasis and dissection during thyroidectomy with that of ultrasonic scalpel.

MATERIALS AND METHODS

Sixty patients underwent total thyroidectomy were recruited at Alshiffa General Hospital, Basrah, Iraq from March 2016 to June 2017. The participants were divided into two equal groups: in the first group thyroid dissection was done with ultrasonic scalpel, and in the second group thyroid dissection was done with bipolar radiofrequency ablation device. Outcome and complications of both procedures were analyzed statistically and compared.

RESULTS

The bipolar radiofrequency ablation device significantly reduced the mean operative time by (-15.35 min) in comparison to ultrasonic scalpel. The Bipolar Radiofrequency Ablation Device (BRFA) group reported a mean operative time of 50.13 ± 14.16 compared to 65.49 ± 7.78 in the US group with, P value = 0.001. There was no statistically significant difference in the other outcome parameters and the rate of complications reported between the two devices during this study.

CONCLUSION

The bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps is a simple, safe, and time-saving adjunct for thyroid surgeries and equally effective as compared to costly instruments like ultrasonic scalpel.

CLINICAL SIGNIFICANCE

The bipolar radiofrequency device can be used in thyroid surgery to secure hemostasis, save time, and cost.

The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery

BACKGROUND

The comprehensive complication index (CCI) integrates all complications of the Clavien-Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC.

METHODS

Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution.

RESULTS

From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p < 0.05). The CCI demonstrated a stronger relationship with hospital stay (ρ = 0.721, p < 0.001) than did the CDC (ρ = 0.634, p < 0.001). For prolonged hospital stays (≥30 days), only the CCI showed a moderate correlation (ρ = 0.544, p = 0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time-event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed.

CONCLUSIONS

The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.

Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey

OBJECTIVE

Ensuring that neonatal-perinatal medicine (NPM) fellows attain competency in performing neonatal procedures is a requirement of training-competent neonatologists.

STUDY DESIGN

A survey of NPM fellows was performed to determine the procedural experience of current fellows, investigate techniques used to track procedural experience and examine the methods programs use to verify procedural competency.

RESULTS

One hundred and sixty-three fellows in 57 accredited training programs responded to the survey. Reported number of procedures provide contemporary normative data on procedural experience during training. The majority of fellows reported using an online reporting system to track experience. The most common technique to verify procedural competency was supervised practice until an arbitrary number of procedures had been performed.

CONCLUSIONS

NPM fellow procedural experience increases significantly for most, but not all, procedures duration training. We speculate that supplemental simulation training for rare neonatal procedures would help ensure the competency of graduating NPM fellows. Experience alone is insufficient to verify competency. Further work on the accurate tracking of experience and verification of procedural competency is needed.

Cumulative summation (CUSUM) charts in the monitoring of hypospadias outcomes: a tool for quality improvement initiative

OBJECTIVE

Cumulative summation (CUSUM) charting is a statistical tool that allows an individual surgeon or surgical department to monitor any binary outcome and rapidly detect when complications are outside the acceptable limits. We applied CUSUM statistical analysis to hypospadias repair to utilize the results in our own quality Improvement process.

MATERIALS AND METHODS

An institutional review board-approved retrospective review of all patients who underwent hypospadias repair by a single fellowship trained pediatric urologist at a single institution between September 2004 to July 2009 was performed. To graphically represent the complication rates and to assess for unacceptable rates, the use of CUSUM control charting was employed.

RESULTS

In our retrospective review, there were a total of 184 patients who underwent a total of 203 surgeries. Using CUSUM analysis, our incidence of major complications was within acceptable limits until approximately the first 150 operations had been performed, at which time the complication rate fell below the lower limit, indicating performance exceeded expectations.

CONCLUSION

CUSUM statistical charting was successfully applied to the retrospective monitoring of hypospadias outcomes at our institution. This is the first known publication in which CUSUM charts were used to evaluate complications of hypospadias repair.

Remnant uptake as a postoperative oncologic quality indicator

BACKGROUND

The purpose of this study was to examine the utility of remnant uptake on postoperative radioiodine scans as an oncologic indicator after thyroidectomy for differentiated thyroid cancer (DTC).

METHODS

We conducted a retrospective review of patients undergoing total thyroidectomy for DTC and subsequent radioactive iodine (RAI) treatment. Of the eight surgeons included, three were considered high volume, performing at least 20 thyroidectomies per year. Patients with distant metastases at diagnosis or poorly differentiated variants were excluded. To control for the effect of varying RAI doses, the remnant uptake was analyzed as a ratio of the percentage uptake to the dose received (uptake to dose ratio [UDR]). Multivariate logistic regression was used to determine the influence of UDR on recurrence.

RESULTS

Of the 223 patients who met inclusion criteria, 21 patients (9.42%) experienced a recurrence. Those with a recurrence had a 10-fold higher UDR compared with those who did not (0.030 vs. 0.003, p=0.001). Similarly, patients with increasing postoperative thyroglobulin measurements (0.339 vs. 0.003, p<0.001) also had significantly greater UDRs compared with those with stable thyroglobulin. The UDRs of high-volume surgeons were significantly smaller than low-volume surgeons (0.003 vs. 0.025, p=0.002). When combined with other known predictors for recurrence, UDR (OR 3.71 [95%CI 1.05-13.10], p=0.041) was significantly associated with recurrence. High-volume surgeons maintained a low level of permanent complications across all UDRs, whereas low-volume surgeons had greater permanent complications associated with higher uptake.

CONCLUSIONS

Remnant uptake is a useful postoperative oncologic quality indicator that can predict a patient's risk of disease recurrence and indicate the completeness of resection.

Laryngeal morbidity after intubation with or without neuromuscular block in thyroid surgery using recurrent laryngeal nerve monitoring

OBJECTIVE

The avoidance of neuromuscular blocking agents (NMBA) for endotracheal intubation is associated with a higher incidence of laryngeal discomfort and lesions, but could impair effectiveness of intra operative recurrent laryngeal nerve monitoring (IONM).

METHODS

In a retrospective quality assessment study over a period of 30 months, a collective that had been intubated without NMBA was compared with a group, which had received NMBA. Endolaryngeal EMG was accomplished with a MagStim(®)-EMG-electrode.

RESULTS

Out of the 127 patients with 224 nerves at risk (NAR; NMBA 102 NAR, no NMBA 122 NAR), more than 90% received a total intravenous anaesthesia with propofol, and 88% had remifentanil. Laryngeal side effects and damage scores did not differ significantly.

CONCLUSIONS

In this special setting of IONM and thyroid surgery, avoidance of NMBA for endotracheal intubation seems not to increase the incidence of laryngeal side effects and lesions. If endotracheal intubation without NMBA is required, the authors suggest a standardized approach using induction agents as propofol and remifentanil.

Comparison of two electromyographical endotracheal tube systems for intraoperative recurrent laryngeal nerve monitoring: reliability and side effects

BACKGROUND

Recurrent laryngeal nerve (RLN) monitoring systems should be reliable and safe. Monitoring via electromyographical systems on an endotracheal tube (ETT) is widely spread. The MagStim™ system consists of an adhesive electrode to be fixed on an endotracheal tube. The Xomed™ endotracheal tube provides integrated electrodes. Reliability and side effects had never been compared. As both systems have very different morphological properties, we hypothesized that there might be differences in reliability and the incidence of side effects.

METHODS

In a retrospective quality management analysis of 118 patients (MagStim™ electrode, 57 patients; Xomed™ ETT, 61 patients), we compared laryngeal side effects according to the Chilla score and detection rate of the RLN.

RESULTS

Both systems had comparable detection rates of the RLN above 95%. Both electrode systems seemed to have similar reliability. Difficulties to detect the nerve were observed in seven patients (four with MagStim, three with Xomed). In the group with the Xomed™ ETT, significantly less mild laryngeal side effects were observed.

CONCLUSION

Both MagStim™ and Xomed™ ETT were reliable in detecting the RLN. The Xomed™ ETT, however, might cause milder laryngeal side effects compared with the MagStim™ electrode.