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Felsted A, Beck AW, Banks CA, Neal D, Columbo JA, Robinson ST, Stone DH, Scali ST. A patient-centered textbook outcome measure effectively discriminates contemporary elective open abdominal aortic aneurysm repair quality. J Vasc Surg 2024:S0741-5214(24)01231-X. [PMID: 38838968 DOI: 10.1016/j.jvs.2024.05.052] [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: 03/24/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND There is persistent controversy surrounding the merit of surgical volume benchmarks being used solely as a sufficient proxy for assessing the quality of open abdominal aortic aneurysm (AAA) repair. Importantly, operative volume quotas may fail to reflect a more nuanced and comprehensive depiction of surgical outcomes most relevant to patients. Accordingly, we herein propose a patient-centered textbook outcome (TO) for AAA repair that is analogous to other large magnitude extirpative operations performed in other surgical specialties, and test its feasibility to discriminate hospital performance using Society for Vascular Surgery (SVS) volume guidelines. METHODS All elective open infrarenal AAA repairs (OAR) in the SVS-Vascular Quality Initiative were examined (2009-2022). The primary end point was a TO, defined as a composite of no in-hospital complication or reintervention/reoperation, length of stay of ≤10 days, home discharge, and 1-year survival rates. The discriminatory ability of the TO measure was assessed by comparing centers that did or did not meet the SVS annual OAR volume threshold recommendation (high volume ≥10 OARs/year; low volume <10 OARs/year). Logistic regression and multivariable models adjusted for patient and procedure-related differences. RESULTS A total of 9657 OARs across 198 centers were analyzed (mean age, 69.5 ± 8.4 years; female, 26%; non-White, 12%). A TO was identified in 44% (n = 4293) of the overall cohort. The incidence of individual TO components included no in-hospital complication (61%), no in-hospital reintervention or reoperation (92%), length of stay of ≤10 days (78%), home discharge (76%), and 1-year survival (91%). Median annual center volume was 6 (interquartile range, 3-10) and a majority of centers did not meet the SVS volume suggested threshold (<10 OARs/year, n = 148 [74%]). However, most patients (6265 of 9657 [65%]) underwent OAR in high-volume hospitals. When comparing high- and low-volume centers, a TO was more likely to occur in high-volume institutions: ≥10 OARs/year (46%) vs <10 OARs/year (42%; P = .0006). The association of a protective effect for higher center volume remained after risk adjustment (odds ratio, 1.1; 95% confidence interval, 1.05-1.26; P = .003). CONCLUSIONS TOs for elective OAR reflect a more nuanced and comprehensive patient centered proxy to measure care delivery, consistent with other surgical specialties. Surprisingly, a TO was achieved in <50% of elective AAA cases nationally. Although the likelihood of a TO seems to correlate with SVS center volume recommendations, it more importantly reflects elements which may be prioritized by patients and thus offers insights into further improving real-world AAA care.
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Affiliation(s)
- Amy Felsted
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Scott T Robinson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
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Partelli S, Fermi F, Fusai GK, Tamburrino D, Lykoudis P, Beghdadi N, Dokmak S, Wiese D, Landoni L, Reich F, Busch ORC, Napoli N, Jang JY, Kwon W, Armstrong T, Allen PJ, He J, Javed A, Sauvanet A, Bartsch DK, Salvia R, van Dijkum EJMN, Besselink MG, Boggi U, Kim SW, Wolfgang CL, Falconi M. The Value of Textbook Outcome in Benchmarking Pancreatoduodenectomy for Nonfunctioning Pancreatic Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:4096-4104. [PMID: 38461463 DOI: 10.1245/s10434-024-15114-1] [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: 10/20/2023] [Accepted: 02/14/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Textbook outcome (TO) is a composite variable that can define the quality of pancreatic surgery. The aim of this study is to evaluate TO after pancreatoduodenectomy (PD) for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs). PATIENTS AND METHODS All patients who underwent PD for NF-PanNETs (2007-2016) in different centers were included in this retrospective study. TO was defined as the absence of severe postoperative complications and mortality, length of hospital stay ≤ 19 days, R0 resection, and at least 12 lymph nodes harvested. RESULTS Overall, 477 patients were included. The TO rate was 32%. Tumor size [odds ratio (OR) 1.696; p = 0.013], a minimally invasive approach (OR 12.896; p = 0.001), and surgical volume (OR 2.062; p = 0.023) were independent predictors of TO. The annual frequency of PDs increased over time as well as the overall rate of TO. At a median follow-up of 44 months, patients who achieved TO had similar disease-free (p = 0.487) and overall survival (p = 0.433) rates compared with patients who did not achieve TO. TO rate in patients with NF-PanNET > 2 cm was 35% versus 27% in patients with NF-PanNET ≤ 2 cm (p = 0.044). Considering only NF-PanNETs > 2 cm, patients with TO and those without TO had comparable 5-year overall survival rates (p = 0.766) CONCLUSIONS: TO is achieved in one-third of patients after PD for NF-PanNETs and is not associated with a benefit in terms of long-term survival.
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Affiliation(s)
- Stefano Partelli
- Pancreatic and Transplant Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
| | - Francesca Fermi
- Pancreatic and Transplant Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Giuseppe K Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Domenico Tamburrino
- Pancreatic and Transplant Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Panagis Lykoudis
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Nassiba Beghdadi
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Safi Dokmak
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Dominik Wiese
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Federico Reich
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - O R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Thomas Armstrong
- Department of Surgery, University Hospital Southampton, Southampton, UK
| | - Peter J Allen
- Department of Surgery, Duke University School of Medicine, Division of Surgical Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Jin He
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD, USA
| | - Ammar Javed
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Medical Center, New York, NY, USA
| | - Alain Sauvanet
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - E J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Christofer L Wolfgang
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Medical Center, New York, NY, USA
| | - Massimo Falconi
- Pancreatic and Transplant Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, San Raffaele Hospital, Milan, Italy
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Villodre C, Del Río-Martín J, Blanco-Fernández G, Cantalejo-Díaz M, Pardo F, Carbonell S, Muñoz-Forner E, Carabias A, Manuel-Vazquez A, Hernández-Rivera PJ, Jaén-Torrejimeno I, Kälviäinen-Mejia HK, Rotellar F, Garcés-Albir M, Latorre R, Longoria-Dubocq T, De Armas-Conde N, Serrablo A, Esteban Gordillo S, Sabater L, Serradilla-Martín M, Ramia JM. Textbook outcome in distal pancreatectomy: A multicenter study. Surgery 2024; 175:1134-1139. [PMID: 38071134 DOI: 10.1016/j.surg.2023.11.012] [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: 04/12/2023] [Revised: 11/01/2023] [Accepted: 11/11/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Textbook outcome is an interesting quality metrics tool. Information on textbook outcomes in distal pancreatectomy is very scarce. In this study we determined textbook outcome in a distal pancreatectomy multicenter database and propose a specific definition of textbook outcome-distal pancreatectomy that includes pancreatic fistula. METHODS Retrospective multicenter observational study of distal pancreatectomy performed at 8 hepatopancreatobiliary surgery units from January 1, 2008, to December 31, 2018. The inclusion criteria were any scheduled distal pancreatectomy performed for any diagnosis and age > 18 years. Specific textbook outcome-distal pancreatectomy was defined as hospital stay P < 75, no Clavien-Dindo complications (≥ III), no hospital mortality, and no readmission recorded at 90 days, and the absence of pancreatic fistula (B/C). RESULTS Of the 450 patients included, 262 (58.2%) obtained textbook outcomes. Prolonged stay was the parameter most frequently associated with failure to achieve textbook outcomes. The textbook outcome group presented the following results. Preoperative: lower American Society of Anesthesiologists score < III, a lower percentage of smokers, and less frequent tumor invasion of neighboring organs or vascular invasion; operative: major laparoscopic approach, and less resection of neighboring organs and less operative transfusion; postoperative: lower percentage of delayed gastric emptying and pancreatic fistula B/C, and diagnosis other an adenocarcinoma. In the multivariate study, the American Society of Anesthesiologists score > II, resection of neighboring organs, B/C pancreatic fistula, and delayed gastric emptying were associated with failure to achieve textbook outcomes. CONCLUSION The textbook outcome rate in our 450 pancreaticoduodenectomies was 58.2%. In the multivariate analysis, the causes of failure to achieve textbook outcomes were American Society of Anesthesiologists score > II, resection of neighboring organs, pancreatic fistula B/C, and delayed gastric emptying. We believe that pancreatic fistula should be added to the specific definition of textbook outcome-distal pancreatectomy because it is the most frequent complication of this procedure.
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Affiliation(s)
- Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain; Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | - Fernando Pardo
- Department of Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | - Silvia Carbonell
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Elena Muñoz-Forner
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | | | | | | | | | | | - Fernando Rotellar
- Department of Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Raquel Latorre
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | | | - Alejandro Serrablo
- Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Luis Sabater
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Mario Serradilla-Martín
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - José M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain; Universidad Miguel Hernández, Alicante, Spain
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4
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Mclauchlan J, de Burlet K, Nonis M, Hore T, Connor S. Textbook outcomes for liver resection: can a medium sized centre have acceptable outcomes? ANZ J Surg 2023; 93:2892-2896. [PMID: 37784257 DOI: 10.1111/ans.18724] [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: 01/02/2023] [Revised: 08/01/2023] [Accepted: 09/16/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Textbook outcome (TO) is an objective, composite measure of clinical outcomes in surgery. TO in liver surgery has been used in previous international studies to define and compare performance across centres. This study aimed to review TO rates following liver resection at a single institution. The secondary aim was to use a CuSum analysis to evaluate monitoring of performance quality over time for colorectal cancer liver metastases (CRCLM). METHODS All patients undergoing liver resection for benign and malignant causes from Christchurch Hospital hepatobiliary unit between 2005 and 2022 were included. Textbook outcomes measures were the absence of; intraoperative incidents, Clavien-Dindo >3 complication, 90 day re-admission, 90 day mortality, R1 resection, and post-operative bile leak/liver failure. Sequential CuSum analysis was performed to review achievement of TO in liver resections for colorectal cancer liver metastases (CRCLM). RESULTS Four hundred and seventy-eight patients were included in this study, 54 had resection for benign pathology, 290 for CRCLM and 134 for other malignancies. TO was achieved in 74% of cases overall, with rates for benign, CRCLM and other malignancy being 82%, 73% and 74% respectively (P = 0.405). CuSum analysis documented a deterioration in performance after patient 60, with return to baseline by end of study period. CONCLUSIONS TO for liver resection in a medium sized centre in New Zealand are comparable to published rates. It is possible to use process control techniques like CuSum with the binary result of TO to monitor performance, providing opportunity for continuous improvement in surgical units.
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Affiliation(s)
- Jared Mclauchlan
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Kirsten de Burlet
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Maria Nonis
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Saxon Connor
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
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5
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Mohamed A, Nicolais L, Fitzgerald TL. Textbook outcome as a composite measure of quality in hepaticopancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1172-1179. [PMID: 37735865 DOI: 10.1002/jhbp.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Textbook outcome (TO) is a valuable metric to assess postoperative outcomes. The aim of this study was to assess TO in patients undergoing hepatopancreatic surgery. METHODS This was a retrospective cohort NSQIP study from 2015 to 2018. TOs are defined as no complication or mortality and length of stay within the 75th percentile. RESULTS This study included 44 235 patients. Of those patients, 61% underwent pancreatic surgery (PS) and 39% hepatic surgery (HS). The most common surgical procedure was pancreaticoduodenectomy (16 464), followed by partial hepatectomy (11 817), distal pancreatectomy (8292), hemihepatectomy (4247), hepatic trisegmentectomy (1366) and total pancreatectomy (706). TO was more common for HS than PS, 47% versus 40%, p < .001. TO was more common for younger (0-65, OR: 1.60; CI: 1.30-1.96, p < .001), female (OR: 1.23; CI: 1.17-1.29, p < .001), white (OR: 1.10; CI: 1.01-1.19, p = .022), and lower ASA class (OR: 2.11; CI: 1.54-2.90, p < .001) patients. For patients undergoing HS TO was more common after partial lobectomy than trisegmentectomy and lobectomy (OR: 1.36; CI: 1.18-1.57, p < .001). For those undergoing PS, there was a lower likelihood of TO for those who are obese/morbidly obese compared to normal-weight patients (OR: 0.73; CI: 0.67-0.79, p < .001). Unlike HS, TO for patients undergoing PS was not associated with the type of surgical procedure. CONCLUSIONS TO is a composite that can be applied to a national data set to analyze outcome quality. In HS, more complex surgical procedures are associated with a decreased likelihood of TO. In PS, TO are similar regardless of the procedure but less common in obese or morbidly obese patients.
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Affiliation(s)
- Abdimajid Mohamed
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
| | - Laura Nicolais
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
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Müller PC, Toti JMA, Guidetti C, Kuemmerli C, Bolli M, Billeter AT, Müller BP. Benchmarking outcomes for distal pancreatectomy: critical evaluation of four multicenter studies. Langenbecks Arch Surg 2023; 408:253. [PMID: 37386208 PMCID: PMC10310555 DOI: 10.1007/s00423-023-02972-8] [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: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Benchmarking is a validated tool for outcome assessment and international comparison of best achievable surgical outcomes. The methodology is increasingly applied in pancreatic surgery and the aim of the review was to critically compare available benchmark studies evaluating distal pancreatectomy (DP). METHODS A literature search of English articles reporting on benchmarking DP was conducted of the electronic databases MEDLINE and Web of Science (until April 2023). Studies on open (ODP), laparoscopic (LDP), and robotic DP (RDP) were included. RESULTS Four retrospective multicenter studies were included. Studies reported on outcomes of minimally invasive DP only (n = 2), ODP and LDP (n = 1), and RDP only (n = 1). Either the Achievable Benchmark of Care™ method or the 75th percentile from the median was selected to define benchmark cutoffs. Robust and reproducible benchmark values were provided by the four studies for intra- and postoperative short-term outcomes. CONCLUSION Benchmarking DP is a valuable tool for obtaining internationally accepted reference outcomes for open and minimally invasive DP approaches with only minor variances in four international cohorts. Benchmark cutoffs allow for outcome comparisons between institutions, surgeons, and to monitor the introduction of novel minimally invasive DP techniques.
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Affiliation(s)
- P C Müller
- Department of Surgery, Clarunis, - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, 4002, Basel, Switzerland
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - J M A Toti
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - C Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - C Kuemmerli
- Department of Surgery, Clarunis, - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, 4002, Basel, Switzerland
| | - M Bolli
- Department of Surgery, Clarunis, - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, 4002, Basel, Switzerland
| | - A T Billeter
- Department of Surgery, Clarunis, - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, 4002, Basel, Switzerland
| | - B P Müller
- Department of Surgery, Clarunis, - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, 4002, Basel, Switzerland.
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Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [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: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
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Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
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Neary C, O'Brien L, McCormack E, Kelly M, Bolger J, McEntee G, Conneely J. Defining a textbook outcome for the resection of colorectal liver metastases. J Surg Oncol 2023; 127:616-624. [PMID: 36541290 DOI: 10.1002/jso.27170] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Textbook outcomes (TBO) are composite measures of care which may be superior in assessing quality compared to traditional methods. We aim to define TBO which are specific to surgical resection of colorectal liver metastases, and investigate their impact on survival. METHODS Single center analysis of all liver resections performed at our center from 2009 to 2020. A Cox model was used to identify perioperative outcomes which impacted on overall survival. These were retained with important postoperative outcomes to form a "TBO." The impact of a TBO on overall survival was investigated using Kaplan-Meier curve analysis. RESULTS TBO was achieved in 72.2% (197/273) of resections. Major morbidity (Clavien-Dindo ≥3) at 19.4% was the major limiting factor in not achieving a TBO. TBO was associated with improved 3-year (77% vs. 55%), 5-year (60.7% vs. 42.5%), and median (93 vs. 44 months) overall survival (log-rank test, p = 0.006). Multivariable analysis revealed age >65 years, American Society of Anaesthesiologists Grade III-IV, and resection of >2 segments as factors predictive of not achieving a TBO. CONCLUSION TBO is a useful composite measure in surgery for colorectal liver metastases. It can highlight areas which may be targeted for quality improvement and be useful as a tool to examine variation between centers. Achieving a TBO is associated with a significant improvement in survival.
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Affiliation(s)
- Colm Neary
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lukas O'Brien
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emilie McCormack
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Kelly
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jarlath Bolger
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gerard McEntee
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John Conneely
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Jaén-Torrejimeno I, Ramia JM, López-Guerra D, Rojas-Holguín A, De-Armas-Conde N, Blanco-Fernández G. Textbook outcome in the surgical treatment of liver hydatid cyst. Surgery 2023; 173:429-434. [PMID: 36334979 DOI: 10.1016/j.surg.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Textbook outcome is a composite measure used in surgery to define the ideal postoperative period and to assess the quality of care. The aim of this study was to analyze the incidence of textbook outcome and the factors independently associated with its achievement following surgical treatment of liver hydatid cysts. METHODS Retrospective cohort study of patients operated on for liver hydatid cysts between January 2006 and December 2021. Textbook outcome was achieved when all the following criteria were fulfilled: no mortality within 90 days, no major complications within 90 days, no hospital readmission within 90 days, and no prolonged hospital stay. Univariable and multivariable analyses were performed to identify factors associated with textbook outcome. RESULTS During the study period, 296 patients underwent surgery. Textbook outcome was recorded in 65.9% (195/296). Female gender (odds ratio 2.02; P = .010), noncomplicated cyst (odds ratio 3.97, P < .001), and radical surgery (odds ratio 2.26, P = .003) were the variables associated with a higher probability of achieving textbook outcome. CONCLUSION Textbook outcome may be a useful measure to assess the variations in surgical management between different centers, and to improve quality of care after liver hydatid cysts resection.
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Affiliation(s)
| | - José M Ramia
- Department of Surgery, Hospital Universitario de Alicante, Spain
| | - Diego López-Guerra
- Department of HBP and Liver Transplant Surgery, Hospital Universitario de Badajoz, Spain; Universidad de Extremadura, Facultad de Medicina y Ciencias de la Salud
| | - Adela Rojas-Holguín
- Department of HBP and Liver Transplant Surgery, Hospital Universitario de Badajoz, Spain; Universidad de Extremadura, Facultad de Medicina y Ciencias de la Salud
| | - Noelia De-Armas-Conde
- Department of HBP and Liver Transplant Surgery, Hospital Universitario de Badajoz, Spain
| | - Gerardo Blanco-Fernández
- Universidad de Extremadura, Facultad de Medicina y Ciencias de la Salud; Department of HBP and Liver Transplant Surgery, Hospital Universitario de Badajoz, Spain.
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Han JS, Dunham CM, Renner CE, Neubauer SA, McCarron FN, Chirichella TJ. Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review. BMC Surg 2022; 22:414. [PMID: 36474230 PMCID: PMC9724418 DOI: 10.1186/s12893-022-01867-7] [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: 07/12/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. METHODS The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital's trauma center had been verified; and (4) the hospital's surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. RESULTS The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien-Dindo grades III-IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732). CONCLUSION Despite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.
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Affiliation(s)
- Jane S. Han
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - C. Michael Dunham
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - Charles E. Renner
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - Steven A. Neubauer
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - F. Nikki McCarron
- grid.443867.a0000 0000 9149 4843Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH 44106 USA
| | - Thomas J. Chirichella
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
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11
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Liu ZP, Yao LQ, Diao YK, Chen ZX, Feng ZH, Gu WM, Chen ZL, Chen TH, Zhou YH, Wang H, Xu XF, Wang MD, Li C, Liang L, Zhang CW, Pawlik TM, Lau WY, Shen F, Chen ZY, Yang T. Association of Preoperative Body Mass Index with Surgical Textbook Outcomes Following Hepatectomy for Hepatocellular Carcinoma: A Multicenter Study of 1206 Patients. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11721-y. [PMID: 35419755 DOI: 10.1245/s10434-022-11721-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/24/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessment of quality in the perioperative period is critical to ensure good patient care. Textbook outcomes (TO) have been proposed to combine several parameters into a single defined quality metric. The association of preoperative body mass index (BMI) with incidences of achieving or not achieving TO (non-TO) among patients undergoing hepatectomy for hepatocellular carcinoma (HCC) was characterized. METHODS Patients who underwent curative-intent hepatectomy for HCC between 2015 and 2018 were identified from a multicenter database. These patients were divided into three groups based on preoperative BMI: low-BMI (≤ 18.4 kg/m2), normal-BMI (18.5-24.9 kg/m2), and high-BMI (≥ 25.0 kg/m2). The incidences of non-TO among these three groups were compared. Multivariate analyses were performed to identify whether there was any independent association between preoperative BMI and non-TO. RESULTS Among 1206 patients, 100 (8.3%), 660 (54.7%), and 446 (37.0%) were in the low-BMI, normal-BMI, and high-BMI groups, respectively. The incidence of non-TO was 65.6% in the whole cohort. The incidence of non-TO was significantly higher among patients in the low- and high-BMI cohorts versus the normal-BMI cohort (75.0% and 74.7% versus 58.0%, both P < 0.01). After adjustment of other confounding factors on multivariate analysis, low-BMI and high-BMI were independently associated with higher incidences of non-TO compared with normal-BMI (OR: 1.98 and 2.27, both P < 0.05). CONCLUSIONS Two out of three patients did not achieve TO after hepatectomy for HCC. Both preoperative low-BMI and high-BMI were independently associated with lower odds to achieve optimal TO following HCC resection.
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Affiliation(s)
- Zhi-Peng Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lan-Qing Yao
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
| | - Yong-Kang Diao
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Cancer Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Zhejiang, China
| | - Zi-Xiang Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Zi-Han Feng
- Department of Hepatobiliary Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Wei-Min Gu
- The First Department of General Surgery, The Fourth Hospital of Harbin, Heilongjiang, China
| | - Zheng-Liang Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Ting-Hao Chen
- Department of General Surgery, Ziyang First People's Hospital, Sichuan, China
| | - Ya-Hao Zhou
- Department of Hepatobiliary Surgery, Pu'er People's Hospital, Yunnan, China
| | - Hong Wang
- Department of General Surgery, Liuyang People's Hospital, Hunan, China
| | - Xin-Fei Xu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
| | - Ming-Da Wang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
| | - Chao Li
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
| | - Lei Liang
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Cancer Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Zhejiang, China
| | - Cheng-Wu Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Cancer Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Zhejiang, China
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China
- Eastern Hepatobiliary Clinical Research Institute (EHCRI), Third Affiliated Hospital of Navy Medical University, Shanghai, China
| | - Zhi-Yu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
| | - Tian Yang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Navy Medical University), Shanghai, China.
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Cancer Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Zhejiang, China.
- Eastern Hepatobiliary Clinical Research Institute (EHCRI), Third Affiliated Hospital of Navy Medical University, Shanghai, China.
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Tsilimigras DI, Pawlik TM, Moris D. Textbook outcomes in hepatobiliary and pancreatic surgery. World J Gastroenterol 2021; 27:1524-1530. [PMID: 33958840 PMCID: PMC8058657 DOI: 10.3748/wjg.v27.i15.1524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
The concept of textbook outcome (TO) has recently gained popularity in surgical research and has been used to evaluate the quality or success of different surgical procedures, including hepatopancreatobiliary (HPB) operations. TO consists of individual outcome parameters that each reflect different domains of care including structure, process, and individual outcomes; in turn, the composite TO metric represents the optimal course after a surgical episode. TO can be used to assess patient-level outcomes, hospital performance, center designation and quality metrics. In addition to being an outcome measurement, TO may also be linked to healthcare costs. Future efforts should be directed towards establishing a universal definition of TO in HPB surgery so that surgeons and hospitals can assess and compare outcomes, identify shortcomings and improve real world patient outcomes.
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Affiliation(s)
| | | | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27710, United States
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