Timing of elective surgery as a perioperative outcome variable: analysis of pancreaticoduodenectomy

Comparing Outcomes for Emergent Cranial Neurosurgical Procedures Performed "During Hours" and "After Hours"

OBJECTIVE

Surgery performed at night and on weekends is thought to be associated with increased complications. However, the impact of time of day on outcomes has not been studied within cranial neurosurgery. We aim to determine if there are differences in outcomes for cranial neurosurgery performed after hours (AH) compared with during hours (DH).

METHODS

We performed a single-center retrospective study of cranial neurosurgery patients who underwent emergent surgery from January 2015 through December 2019. Surgery was considered DH if the incision occurred between 8 am and 5 pm Monday through Friday. We assessed outcome measures for differences between operations performed DH or AH.

RESULTS

Three-hundred and ninety-three patients (114 DH, 279 AH) underwent surgery. There was a lower rate of return to the operating room within 30 days for AH (8.6%) compared with DH (14.0%), P = 0.03, on multivariate analysis. There were no significant differences in length of operation, estimated blood loss, improvement in Glasgow Coma Scale, intensive care unit and total hospital length of stay, 30-day readmission, 30-day mortality, and in-hospital mortality for cases performed DH compared with AH. Further subgroup analyses were performed for patients who underwent immediate surgery for subdural hematomas, with no differences noted in outcomes on multivariate analysis.

CONCLUSIONS

This study suggests that operating AH does not appear to negatively impact outcomes when compared with operating DH, in cases of cranial neurosurgical emergencies. Further study assessing the impact on elective neurosurgical cases is required.

Exploring the Surgical Outcomes of Pancreatic Cancer Resections Performed in Low- Versus High-Volume Centers

Introduction Pancreatic cancer resections comprise a class of complex surgical operations with a high postoperative morbidity rate. Due to the complicated nature of pancreatic resection, individuals who undergo this procedure are advised to visit a high-volume medical center that performs such pancreatic surgeries frequently. However, this specialized treatment option may not be available for uninsured patients or patients with other socioeconomic limitations that may restrict their access to these facilities. To gain a better understanding of the impact of healthcare disparities on surgical outcomes, we aimed to explore if there were significant differences in mortality rate post-pancreatic resection between high- and low-volume hospitals within San Bernardino, Riverside, Los Angeles, and Orange Counties. Methods We utilized the California Health and Human Services Agency (CHHS) California Hospital Inpatient Mortality Rates and Quality Ratings public dataset to compare risk-adjusted mortality rates (RA-MR) of pancreatic cancer resections procedures. We focused on procedures performed in hospitals within San Bernardino, Riverside, Los Angeles, and Orange County from 2012 to 2015. To assess post-resection outcomes in relation to hospital volume, we utilized an independent T-test (significance level was set equal to 0.05) to determine if there is a statistically significant difference in RA-MR after pancreatic resection between high- and low-volume hospitals. Results During the 2012-2015 study period, 57 hospitals across San Bernardino, Riverside, Orange, and Los Angeles Counties were identified to perform a total of 6,204 pancreatic resection procedures. The low-volume hospital group (N=2,539) was associated with a higher RA-MR of M=4.45 (SD=11.86). By comparison, the high-volume hospital group (N=3,665) was associated with a lower RA-MR of M=1.72 (SD=2.61). Conclusion Pancreatic resection surgeries performed at low-volume hospitals resulted in a significantly higher RA-MR compared to procedures done at high-volume hospitals in California.

Day of surgery and mortality after pancreatoduodenectomy: A retrospective analysis of 29 270 surgical cases of pancreatic head cancer from Japan

BACKGROUND/PURPOSE

The day of the week can impact medical treatment outcomes; however, few large-scale, disease-specific studies have focused on the association between the day of the week and mortality in patients after pancreatoduodenectomy for pancreatic head cancer.

METHODS

Data were obtained from the National Clinical Database. Twenty-two clinical variables were adopted for hierarchal logistic regression modeling to determine adjusted odds ratios (ORs) for surgical mortality after elective pancreatoduodenectomy.

RESULTS

The 30-day mortality and surgical mortality rates were 1.0% and 1.7%, respectively (n = 29 720). Surgeries were performed the least on Fridays (13.4%) compared with other weekdays. Crude rates of severe postoperative complications (mean, 14.1%; range, 13.5%-14.8%) and pancreatic fistulas (mean, 10.0%; range, 9.6%-10.3%) remained stable throughout the week. Unadjusted/adjusted ORs did not significantly differ between Friday and Monday (0.868, 95% CI: 0.636-1.173, P = .365, and 0.928, 95% CI: 0.668-1.287, P = .653, respectively), and results were similar for the remaining weekdays. Nineteen independent factors were associated with surgical mortality.

CONCLUSIONS

The rate of perioperative mortality for elective pancreatoduodenectomy is low in Japan, with no evidence of disparities in surgical mortality rates between weekdays.

Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures

Background

Hospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS.

Methods

Retrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student’s t-test. 

Results

9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges. 

Conclusion

Optimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures. 

Early morning kidney transplantation: Perioperative complications

INTRODUCTION

To reduce cold ischemia time (CIT), many kidney transplants are performed in the early morning. Conducting complex surgeries in the early morning may influence the surgeon's technical capacity and rate of surgical complications (SC).

AIM

Evaluate the influence of surgery start hour (SSH) regarding duration of surgery (DS), immediate diuresis (ID), SC and acute rejection (AR); evaluate the influence of CIT regarding SC, ID, and AR.

METHODS

2855 cadaveric transplants performed between June 1980 and March 2018 were retrospectively evaluated. Regarding SSH, two groups were created: Group M (00: 00h-05.59h, n = 253) and Group D (06: 00h - 23: 59h, n = 2602). Analyzing the impact of SSH on DS, ID, SC and AR. Evaluate the relationship between CIT (< 18h, 18-30h and > 30h) on ID, SC and AR utilizing univariate and multivariate statistical analysis with SPSS.

RESULTS AND CONCLUSION

Groups M and D were comparable in all evaluated demographic variables (p > 0.05), except cold ischemia time (Group M with higher CIT, p < 0.001). Regarding univariate analysis, Surgery start hour did not influence DS (p = 0.344), and SC (p = 0.264), but related with higher ID (p = 0.028) and AR (p = 0.018). CIT related with immediate diuresis (p = 0.020) and acute rejection (p < 0.001) but did not relate with complications (p = 0.734). Regarding multivariate analysis, SSH only influenced immediate diuresis (p = 0.026) and did not influenced acute rejection (p = 0.055). CIT influenced immediate diuresis (p = 0.019) and acute rejection (p < 0.001). Surgery start hour influences Immediate diuresis. With this study, we conclude that the priority must be a short cold ischemia time.

Impact of surgeon work duration prior to distal pancreatectomy on perioperative outcomes: a propensity score matching analysis

BACKGROUND

Surgeons are likely to get progressively fatigued during the course of a normal workday. The objective of this study was to evaluate the impact of surgeon work duration prior to performing distal pancreatectomy (DP) on the perioperative outcome, especially frequency of grade II or higher grade postoperative complications.

METHODS

Patients undergoing DP for all causes were divided into two groups according to surgeon work hours prior to performing DP: group A (less than 5 h) and group B (5-10 h). Propensity score matching (PSM) analysis (1:1) were performed to balance the baseline characteristics between the two groups. Intraoperative complications were compared between the two groups. Postoperative complications and their severity were followed up for 60 days and mortality for 90 days. The study was powdered to identify a 15% difference in the incidence of grade II or higher grade complications.

RESULTS

By using PSM analysis, the patients in group A (N = 202) and group B (N = 202) were well matched regarding demographics, comorbidities, operative technique, pancreatic texture and pathology. There was no significant difference in the incidence of grade II or higher grade complications between the two groups. There was no difference in clinically relevant postoperative pancreatic fistula, percutaneous drainage, readmission, reoperation, or morality. Group B was associated with a higher incidence of intraoperative organ injury, which could be managed successfully during the operation.

CONCLUSION

The retrospective study demonstrated that the surgeon work duration did not significantly affect the clinical outcome of DP.

Seasonal variations in pancreatic surgery outcome A retrospective time-trend analysis of 2748 Whipple procedures

Background

Observing cyclic patterns in surgical outcome is a common experience. We aimed to measure this phenomenon and to hypothesize possible causes using the experience of a high-volume pancreatic surgery department.

Methods

Outcomes of 2748 patients who underwent a Whipple procedure at a single high-volume center from January 2000 to December 2018 were retrospectively analyzed. Three different hypotheses were tested: the effect of climate changes, the “July effect” and the effect of vacations.

Results

Clavien-Dindo ≥ 3 morbidity was similar during warm vs. cold months (22.5% vs. 19.8%, p = 0.104) and at the beginning of activity of new trainees vs. the rest of the year (23.5 vs. 22.5%, p = 0.757). Patients operated when a high percentage of staff is on vacation showed an increased Clavien-Dindo ≥ 3 morbidity (22.3 vs. 18.5%, p = 0.022), but similar mortality (2.3 vs. 1.8%, p = 0.553). The surgical waiting list was also significantly longer during these periods (37 vs. 27 days, p = 0.037). Being operated in such a period of the year was an independent predictor of severe morbidity (OR 1.271, CI 95% 1.086–1.638, p = 0.031).

Conclusion

Being operated when more staff is on vacation significantly affects severe morbidity rate. Future healthcare system policies should prevent the relative shortage of resources during these periods.

Blumgart method using LAPRA-TY clips facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy.We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group).The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39-79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53-105 min, P < .001).Although the modified Blumgart pancreaticojejunostomy using LAPRA-TY suture clips did not improve the pancreatic fistula rate, it allowed for shorter operative times. Thus, this procedure lends itself to positive surgical and patient outcomes.

Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis

Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.

Two open whipples a day: Excessive or efficient

BACKGROUND

Demand for pancreatic surgery is rising, occasionally necessitating consecutive PDs to be performed by a single surgeon in the same workday. The safety of this practice is unknown.

METHODS

Institutional prospective ACS-NSQIP data were reviewed for PDs (2013-2017). Instances where a single surgeon performed two PDs in the same day were a PD pair (PD1, PD2) and compared with univariable analysis. Paired vs. unpaired-PD matched analyses were performed.

RESULTS

661 PDs (25-PD pairs) were performed. PD1 and PD2 revealed similar infectious (12% vs16%), pulmonary (8% vs8%), cardiovascular (12% vs4%), and aggregate (24% vs24%) morbidity (P>0.05). Pancreatic fistula (B + C 0%), delayed gastric emptying (4% vs12%), hospital stay (9.3 vs8.8 days), and 30-day mortality (4% vs4%) were similar (P > 0.05). Matched outcomes were similar except higher cardiovascular morbidity for paired vs. unpaired PD (7% vs0%; P = 0.015).

CONCLUSION

With proper patient selection, and in experienced hands at high-volume centers, two consecutive open PDs may be safely performed.

Surgical timing and presence of a vitreoretinal fellow on postoperative adverse events following pars plana vitrectomy

INTRODUCTION

To evaluate the adverse event rate following pars plana vitrectomy as a function of surgical start time and the presence of a vitreoretinal fellow.

METHODS

Single-institution retrospective cohort study of patients undergoing pars plana vitrectomy from 1 January 2016 to 31 December 2016 at Stanford University School of Medicine (Palo Alto, CA, USA). Records were reviewed for surgical start time, the presence of vitreoretinal fellow, and postoperative adverse events defined as any finding deviating from the expected postoperative course requiring observation or intervention.

RESULTS

A total of 310 pars plana vitrectomies were performed. There was no statistical difference in the rate of any adverse event when comparing cases starting after 16:01 (9/13, 69.2%) and after 12:01 (42/99, 42.4%) to a morning start time (69/198, 34.9%, adjusted p = 0.083). There was a statistically significant increase in the risk of postoperative vitreous hemorrhage with afternoon and evening cases as compared to morning cases (adjusted p = 0.021). In addition, there was no difference in any adverse event with a fellow present (93/244, 38.1%) compared to without (27/66, 40.9%, adjusted p = 0.163). There was a higher risk of postoperative hypotony when a fellow was involved (6.6% vs 0%, p = 0.028), though this difference disappeared after adjusting for confounders (adjusted p = 0.252). There was no difference in the length of surgery with and without a fellow (49 vs 54 min, respectively; p = 0.990).

DISCUSSION

Afternoon start time and the presence of a fellow were not independent risk factors for postoperative adverse events.

What Influence Does the Time of Year Have on Postoperative Complications Following Total Knee Arthroplasty?

BACKGROUND

The time of year might influence the occurrence of surgical complications. Therefore, this study investigated correlations between the time-of-year and 30-day postoperative complication rates following primary total knee arthroplasty (TKA). Specifically, we determined (1) postoperative complication rates across all quarters; and (2) time-of-year influence on complications using univariate and multivariate regression analyses.

METHODS

CPT code 27447 identified 147,473 TKAs from the NSQIP database. Readmissions, reoperations, as well as medical and surgical complications occurring within 30 postoperative days were assessed. All TKAs were divided into 4 cohorts based on the quarter-of-the-year (Q1-Q4) during which the surgery was performed. Chi-Square, ANOVA, linear regression, as well as univariate and multivariate analyses were performed to compare complication rates. A P < .05 was set for statistical significance.

RESULTS

Q3 had a higher risk of superficial infection when compared to Q1 (OR 1.37; 95% CI 1.12-1.69; P = .002). There was a lower risk of pneumonia between Q2 and Q1 (OR: 0.7; 95% CI 0.54-0.90; P = .007) as well as Q4 and Q1 (OR 0.76; 95% CI 0.6-0.96; P = .017). Blood transfusion was lower in Q2, Q3, and Q4 compared to Q1 (P = .02, P < .001, and P < .001).

CONCLUSION

This study provides a baseline analysis correlating the time of year and outcomes of TKA. However, since seasonality and weather can vary greatly in the United States by geographic region and time of year, future studies should be performed at a more granular level using hospital-specific data correlating weather and region to TKA outcomes.

Weekend Surgical Care and Postoperative Mortality: A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

An association between weekend health care delivery and poor outcomes has become known as the "weekend effect." Evidence for such an association among surgery patients has not previously been synthesized.

OBJECTIVE

To systematically review associations between weekend surgical care and postoperative mortality.

METHODS

We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models.

RESULTS

Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97-1.11); Wednesday OR=1.08 (95% CI=0.98-1.19); Thursday OR=1.12 (95% CI=1.03-1.22); Friday OR=1.24 (95% CI=1.10-1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08-1.49).

CONCLUSIONS

Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.

Laparoscopic-adapted Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure that is becoming increasingly popular among surgeons. Postoperative pancreatic fistula (POPF) remains the most feared specific complication in reconstruction after PD. The Blumgart anastomosis (BA) has been established as one of the safest anastomosis for pancreas remnant reconstruction, with low rates of POPF and postoperative complications. The procedure for performing this anastomosis by laparoscopic approach has not been reported to date.

METHODS

We describe our technique of LPD with laparoscopic-adapted BA (LapBA) and present the results obtained. A case-matched analysis with open cases of BA is also reported.

RESULTS

Since February 2013 to February 2016, thirteen patients were operated of LapBA. An equivalent cohort of open PD patients was obtained by matching sex, ASA, pancreas consistency and main pancreatic duct diameter. Severe complications (grades III-IV) and length of stay were significantly lesser in LapBA group. No differences in POPF, readmission, reoperation rate and mortality were detected.

CONCLUSIONS

The LapBA technique we propose can facilitate the pancreatic reconstruction after LPD. In this case-matched study, LPD shows superior results than open PD in terms of less severe postoperative complications and shorter length of stay. Randomized control trials are required to confirm these results.

Impact of day of week on outcomes of endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Outcomes for some surgical procedures are discrepantly affected by the day of the week when surgery is performed. It remains unknown whether this finding is applicable to endoscopic sinus surgery (ESS).

METHODS

A retrospective analysis of a cohort from a prospective observational study of patients undergoing ESS for chronic rhinosinusitis. Primary outcome measures included major postoperative complications (epistaxis that required physician intervention, orbital injury, and cerebrospinal fluid leak) as well as Sinonasal Outcomes Test 22 (SNOT-22) and Chronic Sinusitis Survey (CSS) quality-of-life symptom scores at 3 months, 1 year, and 2 years. Associations between the day of the week when ESS was performed and outcome measures were performed when controlling for patients' clinical and demographic characteristics.

RESULTS

The study population consisted of 544 patients with a 30-day major postoperative complications rate of 1.2%. There was no predilection for ESS complications by the day of the week. In comparison with ESS on a Monday, improvement in the SNOT-22 score was no different than with ESS performed on Tuesday (p = 0.800 at 3 months, p = 0.149 at 12 months, p = 0.123 at 24 months), Wednesday (p = 0.533 at 3 months, p = 0.708 at 12 months, p = 0.107 at 24 months), and Thursday (p = 0.965 at 3 months, p = 0.959 at 12 months, p = 0.501 at 24 months). No surgeries were performed on Friday. Similar results were found for improvement in CSS scores.

CONCLUSION

The day of the week on which ESS was performed did not impact surgical outcomes. These results provided novel insights, which may be useful for preoperative discussions with patients and scheduling of ESS.

Tumor recurrence is independent of pancreatic fistula in patients after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

BACKGROUND

Recurrence of pancreatic adenocarcinoma after pancreaticoduodenectomy (PD) can be increased in patients with pancreatic fistula (PF). The purpose of our study was to determine if a relationship exists between PF and tumor recurrence (both peritoneal and local) in patients after PD for pancreatic ductal adenocarcinoma.

STUDY DESIGN

A single-institution, retrospective analysis of 221 patients who underwent PD from January 2001 to December 2009 was conducted. Electronic charts and medical records were queried for tumor characteristics, recurrence, and complications. Presence and grading of PF was determined using the criteria of the International Study Group on Pancreatic Fistula. Data were analyzed using chi-square and Kaplan-Meier survival statistics.

RESULTS

There were 114 male and 107 female patients. Mean age was 66 years (range 35 to 91 years). The vast majority (84%) of patients had stage II disease; 143 (65%) had positive lymph nodes (median 2 positive nodes; range 1 to 17 positive nodes). Pancreatic fistula developed in 23 patients (grade A, n = 9; grade B, n = 13; grade C, n = 1; 10.2%). Peritoneal recurrence was noted in 20 patients (9%). Of the 23 patients with PF, peritoneal recurrence developed in 3 (13%). Of the 198 patients without PF, peritoneal recurrence developed in 17 (10%). Local recurrence occurred in 47 patients (21%), 5 (2%) in patients with PF and 42 (21%) in those without PF (p = NS). In Kaplan-Meier survival analysis, there was no significant difference in recurrence-free survival (p = 0.4) and overall survival (p = 0.3) for those with PF vs those without PF.

CONCLUSIONS

Patients with PF after PD were not found to have a significant increase in local or peritoneal recurrence. Therefore, in this analysis, postoperative PF does not appear to serve as an adverse prognostic marker.