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Kuemmerli C, Balzano G, Bouwense SA, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillarisetty VG, Pucci MJ, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Armstrong M, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Rozzini R, Abu Hilal M. Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis. J Hepatobiliary Pancreat Sci 2024. [PMID: 38282543 DOI: 10.1002/jhbp.1417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). METHODS Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70-79 years) and older patients (≥80 years). RESULTS IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65-1.29], p = .596 and OR 1.22 [95% CI: 0.61-2.46], p = .508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (-0.14 days [95% CI: -0.29 to 0.01], p = .071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (-0.28 days [95% CI: -0.62 to 0.05], p = .069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (-0.36 days [95% CI: -0.71 to -0.004], p = .048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. CONCLUSION ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases Basel, Basel, Switzerland
| | - Gianpaolo Balzano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sara K Daniel
- HPB Surgery, University of Washington, Seattle, Washington, USA
| | | | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Michael J Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | | | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Misha Armstrong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Athens, Greece
| | - Renzo Rozzini
- Geriatrics Operating Units, Foundation Poliambulanza, Brescia, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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2
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Kuemmerli C, Tschuor C, Kasai M, Alseidi AA, Balzano G, Bouwense S, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Liang T, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillai SA, Pillarisetty VG, Pucci MJ, Su W, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Abu Hilal M. Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis. Br J Surg 2022; 109:256-266. [PMID: 35037019 DOI: 10.1093/bjs/znab436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. METHODS The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. RESULTS Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate. CONCLUSION ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis-University Centre for Gastrointestinal and Liver Diseases Basle, Basle, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Adnan A Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sara K Daniel
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Michael J Passeri
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Sastha Ahanatha Pillai
- Department of Surgery, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, India
| | - Venu G Pillarisetty
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wei Su
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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3
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Kagedan DJ, Takabe K. Exploring the lengthiest ambulatory breast surgery clinic appointments: is the patient the problem? Gland Surg 2021; 10:551-558. [PMID: 33708538 DOI: 10.21037/gs-20-623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Prolonged outpatient clinic appointments can disrupt schedules, impacting patients and providers. We sought to define features of the longest ambulatory appointments in a breast surgery clinic, and to ascertain whether patients attending these appointments consistently have protracted appointments. Methods A single-institution retrospective cohort study was conducted of breast surgery clinic patients, January 2017 to May 2019, and the longest 1% of appointments identified using a real-time patient tracking system. A primary chart review was performed, and data abstracted. Other appointments attended by these patients were identified, and the ratio of appointments >75th percentile duration (protracted appointments) to the total appointments during the study period was calculated, enabling comparison for patients with consistently protracted (ratio >50%) vs. sporadically protracted appointments (≤50%). Descriptive analysis was performed, and results reported as medians with inter-quartile ranges. Results A total of 15,265 clinic appointments were identified, and the longest 148 (exceeding 244 minutes) analyzed. Median appointment length was 264 minutes (inter-quartile range: 253-290). 70% were new patient appointments, and 54% of patients underwent a test/investigation that day. A minority were obese (39%), smokers (41%), diagnosed with a psychiatric comorbidity (34%), had a genetic cancer syndrome (22%), or received unexpected news at their appointment (16%). Of 118 patients with multiple appointments, 26% had consistently protracted appointments and 74% sporadically protracted appointments. Conclusions The lengthiest appointments are usually newly diagnosed cancer patients. Only a minority of patients have consistently protracted appointments, implying that a patient's previously prolonged appointment may not predict future long appointments.
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Affiliation(s)
- Daniel J Kagedan
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kazuaki Takabe
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
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4
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Vela N, Davis LE, Cheng SY, Hammad A, Liu Y, Kagedan DJ, Paszat L, Bubis LD, Earle CC, Myrehaug S, Mahar AL, Mittmann N, Coburn NG. Economic Analysis of Adjuvant Chemoradiotherapy Compared with Chemotherapy in Resected Pancreas Cancer. Ann Surg Oncol 2019; 26:4193-4203. [PMID: 31535303 DOI: 10.1245/s10434-019-07808-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Population-based survival and costs of pancreas adenocarcinoma patients receiving adjuvant chemoradiation and chemotherapy following pancreaticoduodenectomy are poorly understood. METHODS This retrospective cohort study used linked administrative and pathological datasets to identify all patients diagnosed with pancreas adenocarcinoma and undergoing pancreaticoduodenectomy in Ontario between April 2004 and March 2014, who received postoperative chemoradiation or chemotherapy. Stage and margin status were defined by using pathology reports. Kaplan-Meier and Cox proportional hazards regression survival analyses were used to determine associations between adjuvant treatment approach and survival, while stratifying by margin status. Median overall health system costs were calculated at 1 and 3 years for chemoradiation and chemotherapy, and differences were tested using the Kruskal-Wallis test. RESULTS Among 709 patients undergoing pancreaticoduodenectomy for pancreas cancer during the study period, the median survival was 21 months. Median survival was 19 months for chemoradiation and 22 months for chemotherapy. Patients receiving chemoradiation were more likely to have positive margins: 47.7% compared with 19.2% in chemotherapy. After stratifying by margin status and controlling for confounders, adjusted hazard ratio of death were not statistically different between chemotherapy and chemoradiation [margin positive, hazard ratio (HR) = 0.99, 95% confidence interval (CI) = 0.88-1.27; margin negative, HR 0.95, 95% CI 0.91-1.18]. Overall 1-year health system costs were significantly higher for chemoradiation (USD $70,047) than chemotherapy (USD $54,005) (p ≤ 0.001). CONCLUSIONS Chemotherapy and chemoradiation yielded similar survival, but chemoradiation resulted in higher costs. To create more sustainable healthcare systems, both the efficacy and costs of therapies should be considered.
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Affiliation(s)
- Nivethan Vela
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Ahmed Hammad
- Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt
| | - Ying Liu
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Lawrence Paszat
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Division of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Lev D Bubis
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Sten Myrehaug
- Division of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Natalie G Coburn
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada. .,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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5
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Pang G, Look Hong NJ, Paull G, Dobransky J, Kupper S, Hurton S, Kagedan DJ, Quan ML, Helyer L, Nessim C, Wright FC. Squamous Cell Carcinoma with Regional Metastasis to Axilla or Groin Lymph Nodes: a Multicenter Outcome Analysis. Ann Surg Oncol 2019; 26:4642-4650. [PMID: 31440926 DOI: 10.1245/s10434-019-07743-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) of the trunk/extremities with nodal metastasis represents a rare but significant clinical challenge. Treatment patterns and outcomes are poorly described. PATIENTS AND METHODS Patients with cSCC who developed axilla/groin lymph node metastasis and underwent curative-intent surgery between 2005 and 2015 were identified at four Canadian academic centers. Demographics, tumor characteristics, treatment patterns, recurrence rates, and mortality were described. Overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan-Meier analysis. Predictors of survival and any recurrence were explored using Cox regression and logistic regression models, respectively. RESULTS Of 43 patients, 70% were male (median age 74 years). Median follow-up was 38 months. Median time to nodal metastasis was 11.3 months. Thirty-one and 12 patients had nodal metastasis to the axilla and groin, respectively. A total of 72% and 7% received adjuvant and neoadjuvant radiation, respectively, while 5% received adjuvant chemotherapy. Following surgery, 26% patients developed nodal and/or distant disease recurrence. Crude mortality rate was 39.5%. Mean OS was 5.3 years [95% confidence interval (CI) 3.9-6.8 years], and 5-year OS was 55.1%. Mean DFS was 4.8 years (95% CI 3.3-6.2 years), and five-year DFS was 49.3%. Any recurrence was the only independent predictor of death [p = 0.036, odds ratio (OR) = 29.5], and extracapsular extension (p = 0.028, OR = 189) and age (p = 0.017, OR = 0.823) were independent predictors of recurrence. CONCLUSIONS This represents the largest contemporary series to date of outcomes for patients with axilla/groin nodal metastases from cSCC. Despite aggressive treatment, outcomes remain modest, indicating the need for a continued multidisciplinary approach and integration of new systemic agents.
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Affiliation(s)
- George Pang
- Department of Surgery, Western University, London, ON, Canada.
| | | | - Gabrielle Paull
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Suzana Kupper
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Scott Hurton
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Daniel J Kagedan
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - May Lynn Quan
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Lucy Helyer
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Carolyn Nessim
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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6
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Abraham L, Goyert N, Kagedan DJ, MacNeill A, Cleghorn MC, Hallet J, Quereshy FA, Coburn NG. Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending. Can J Surg 2018; 61:392-397. [PMID: 30265642 DOI: 10.1503/cjs.014817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy. METHODS Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars. RESULTS Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases. CONCLUSION Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.
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Affiliation(s)
- Liza Abraham
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Nik Goyert
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Daniel J Kagedan
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Andrea MacNeill
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Michelle C Cleghorn
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Julie Hallet
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Fayez A Quereshy
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Natalie G Coburn
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
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7
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Kagedan DJ, Mosko JD, Dixon ME, Karanicolas PJ, Wei AC, Goyert N, Li Q, Mittmann N, Coburn NG. Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial. ACTA ACUST UNITED AC 2018; 25:e430-e435. [PMID: 30464694 DOI: 10.3747/co.25.4007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. Methods This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Results Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Conclusions Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - J D Mosko
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON
| | - M E Dixon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - P J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON
| | - A C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - N Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - Q Li
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - N Mittmann
- Health Outcomes and PharmacoEconomic Research Centre, Toronto, ON
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON
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8
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Kagedan DJ, Devitt KS, Tremblay St-Germain A, Ramjaun A, Cleary SP, Wei AC. The economics of recovery after pancreatic surgery: detailed cost minimization analysis of an enhanced recovery program. HPB (Oxford) 2017; 19:1026-1033. [PMID: 28865739 DOI: 10.1016/j.hpb.2017.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/10/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CPW) are considered safe and effective at decreasing postoperative length of stay (LoS), but the effect on economic costs is uncertain. This study sought to elucidate the effect of a CPW on direct hospitalization costs for patients undergoing pancreaticoduodenectomy (PD). METHODS A CPW for PD patients at a single Canadian institution was implemented. Outcomes included LoS, 30-day readmissions, and direct costs of hospital care. A retrospective cost minimization analysis compared patients undergoing PD prior to and following CPW implementation, using a bootstrapped t test and deviation-based cost modeling. RESULTS 121 patients undergoing PD after CPW implementation were compared to 74 controls. Index LoS was decreased following CPW implementation (9 vs. 11 days, p = 0.005), as was total LoS (10 vs. 11 days, p = 0.003). The mean total cost of postoperative hospitalization per patient decreased in the CPW group ($15,678.45 CAD vs. $25,732.85 CAD, p = 0.024), as was the mean 30-day cost including readmissions ($16,627.15 CAD vs. $29,872.72 CAD, p = 0.016). Areas of significant cost savings included laboratory tests and imaging investigations. CONCLUSIONS CPWs may generate cost savings by reducing unnecessary investigations, and improve quality of care through process standardization and decreasing practice variation.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Katharine S Devitt
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - Aliya Ramjaun
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sean P Cleary
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alice C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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9
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Tremblay St-Germain A, Devitt KS, Kagedan DJ, Barretto B, Tung S, Gallinger S, Wei AC. The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy. HPB (Oxford) 2017; 19:799-807. [PMID: 28578825 DOI: 10.1016/j.hpb.2017.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/28/2017] [Accepted: 04/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW. METHODS We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development. RESULTS 122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03). CONCLUSION Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.
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Affiliation(s)
| | - Katharine S Devitt
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Beverly Barretto
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stephanie Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Steven Gallinger
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alice C Wei
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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10
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Mahar AL, Kagedan DJ, Hallet J, Coburn NG. Re: Secondary gastric cancer following a breast cancer diagnosis; beware of metastatic breast cancer. Breast 2017; 35:221. [PMID: 28774554 DOI: 10.1016/j.breast.2017.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alyson L Mahar
- Sunnybrook Research Institute, Toronto, Canada; Sunnybrook Research Institute, 2075 Bayview Ave, Rm K3W-13, Toronto ON, M4N 3M5, Canada
| | - Daniel J Kagedan
- Sunnybrook Research Institute, Toronto, Canada; Department of Surgery, University of Toronto, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite T2-11, Toronto ON, M4N 3M5, Canada
| | - Julie Hallet
- Sunnybrook Research Institute, Toronto, Canada; Department of Surgery, University of Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room T2 63, Toronto ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Sunnybrook Research Institute, Toronto, Canada; Department of Surgery, University of Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Canada.
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11
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Mahar AL, Kagedan DJ, Hallet J, Coburn NG. Secondary gastric cancer malignancies following a breast cancer diagnosis: A population-based analysis. Breast 2017; 33:34-37. [DOI: 10.1016/j.breast.2017.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/18/2017] [Accepted: 02/20/2017] [Indexed: 01/22/2023] Open
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12
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Kagedan DJ, Goyert N, Li Q, Paszat L, Kiss A, Earle CC, Karanicolas PJ, Wei AC, Mittmann N, Coburn NG. The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy. J Gastrointest Surg 2017; 21:506-515. [PMID: 28058617 DOI: 10.1007/s11605-016-3346-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. METHODS A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. RESULTS Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers. CONCLUSION Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nik Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Lawrence Paszat
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Alice C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. .,, 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada.
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13
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Kagedan DJ, Dixon ME, Raju RS, Li Q, Elmi M, Shin E, Liu N, El-Sedfy A, Paszat L, Kiss A, Earle CC, Mittmann N, Coburn NG. Predictors of adjuvant treatment for pancreatic adenocarcinoma at the population level. ACTA ACUST UNITED AC 2016; 23:334-342. [PMID: 27803598 DOI: 10.3747/co.23.3205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use. METHODS In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005-2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt. RESULTS Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 (p = 0.002), multivariate analysis revealed widespread variation between the treating hospitals (p = 0.001), and even between high-volume hepatopancreatobiliary hospitals (p = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx. CONCLUSIONS Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - M E Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, U.S.A
| | - R S Raju
- Sunnybrook Health Sciences Centre
| | - Q Li
- Institute for Clinical Evaluative Sciences and
| | - M Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - E Shin
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences and
| | - A El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, U.S.A
| | - L Paszat
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | - A Kiss
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Institute of Health Policy, Management and Evaluation, University of Toronto and
| | - C C Earle
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | | | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON;; Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON;; Institute of Health Policy, Management and Evaluation, University of Toronto and
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14
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Poushay HM, Kagedan DJ, Hallet J, Beyfuss K, Nadler A, Ahmed NA, Wright FC. Retirement and the General Surgeon: A Practice Survey of Intentions and Perceptions. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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15
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Kagedan DJ, Frankul F, El-Sedfy A, McGregor C, Elmi M, Zagorski B, Dixon ME, Mahar AL, Vasilevska-Ristovska J, Helyer L, Rowsell C, Swallow CJ, Law CH, Coburn NG. Negative predictive value of preoperative computed tomography in determining pathologic local invasion, nodal disease, and abdominal metastases in gastric cancer. ACTA ACUST UNITED AC 2016; 23:273-9. [PMID: 27536178 DOI: 10.3747/co.23.3124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Before undergoing curative-intent resection of gastric adenocarcinoma (ga), most patients undergo abdominal computed tomography (ct) imaging to determine contraindications to resection (local invasion, distant metastases). However, the ability to detect contraindications is variable, and the literature is limited to single-institution studies. We sought to assess, on a population level, the clinical relevance of preoperative ct in evaluating the resectability of ga tumours in patients undergoing surgery. METHODS In a provincial cancer registry, 2414 patients with ga diagnosed during 2005-2008 at 116 institutions were identified, and a primary chart review of radiology, operative, and pathology reports was performed for all patients. Preoperative abdominal ct reports were compared with intraoperative findings and final pathology reports (reference standard) to determine the negative predictive value (npv) of ct in assessing local invasion, nodal involvement, and intra-abdominal metastases. RESULTS Among patients undergoing gastrectomy, the npv of ct imaging in detecting local invasion was 86.9% (n = 536). For nodal metastasis, the npv of ct was 43.3% (n = 450). Among patients undergoing surgical exploration, the npv of ct for intra-abdominal metastases was 52.3% (n = 407). CONCLUSIONS Preoperative abdominal ct imaging reported as negative is most accurate in determining local invasion and least accurate in nodal assessment. The poor npv of ct should be taken into account when selecting patients for staging laparoscopy.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON; Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - F Frankul
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON
| | - A El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, U.S.A
| | - C McGregor
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON
| | - M Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON; Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - B Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - M E Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, U.S.A
| | - A L Mahar
- Department of Public Health Sciences, Queen's University, Kingston, ON
| | | | - L Helyer
- Division of General Surgery, Dalhousie University, Halifax, NS
| | - C Rowsell
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON
| | - C J Swallow
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - C H Law
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON; Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON; Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
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16
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Mahar AL, Coburn NG, Kagedan DJ, Viola R, Johnson AP. Regional variation in the management of metastatic gastric cancer in Ontario. ACTA ACUST UNITED AC 2016; 23:250-7. [PMID: 27536175 DOI: 10.3747/co.23.3123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Geographic variation in cancer care is common when clear clinical management guidelines do not exist. In the present study, we sought to describe health care resource consumption by patients with metastatic gastric cancer (gc) and to investigate the possibility of regional variation. METHODS In this population-based cohort study of patients with stage iv gastric adenocarcinoma diagnosed between 1 April 2005 and 31 March 2008, chart review and administrative health care data were linked to study resource utilization outcomes (for example, clinical investigations, treatments) in the province of Ontario. The study took a health care system perspective with a 2-year time frame. Chi-square tests were used to compare proportions of resource utilization, and analysis of variance compared mean per-patient resource consumption between geographic regions. RESULTS A cohort of 1433 patients received 4690 endoscopic investigations, 12,033 computed tomography exams, 12,774 radiography exams, and 5059 ultrasonography exams. Nearly all patients were seen by a general practitioner (98%) and a specialist (99%), and were hospitalized (95%) or visited the emergency department (87%). Fewer than half received chemotherapy (43%), gastrectomy (37%), or radiotherapy (28%). The mean number of clinical investigations, physician visits, hospitalizations, and instances of patient accessing the emergency department or receiving radiotherapy or stent placement varied significantly by region. CONCLUSIONS Variations in health care resource utilization for metastatic gc patients are observed across the regions of Ontario. Whether those differences reflect differential access to resources, patient preference, or physician preference is not known. The observed variation might reflect a lack of guidelines based on high-quality evidence and could partly be ameliorated with regionalization of gc care to high-volume centres.
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Affiliation(s)
- A L Mahar
- Department of Public Health Sciences, Queen's University, Kingston, ON;; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre
| | - N G Coburn
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute of Health Policy, Management and Evaluation, University of Toronto and; Institute for Clinical Evaluative Sciences, Toronto, ON
| | - D J Kagedan
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre
| | - R Viola
- Department of Public Health Sciences, Queen's University, Kingston, ON;; Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON
| | - A P Johnson
- Department of Public Health Sciences, Queen's University, Kingston, ON;; Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON.; Centre for Health Services and Policy Research, Queen's University, Kingston, ON
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17
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Kagedan DJ, Abraham L, Goyert N, Li Q, Paszat LF, Kiss A, Earle CC, Mittmann N, Coburn NG. Beyond the dollar: Influence of sociodemographic marginalization on surgical resection, adjuvant therapy, and survival in patients with pancreatic cancer. Cancer 2016; 122:3175-3182. [DOI: 10.1002/cncr.30148] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/02/2016] [Accepted: 05/18/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Daniel J. Kagedan
- Division of General Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Liza Abraham
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
| | - Nik Goyert
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Lawrence F. Paszat
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Craig C. Earle
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Natalie G. Coburn
- Division of General Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
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18
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Yohanathan L, Coburn NG, McLeod RS, Kagedan DJ, Pearsall E, Zih FSW, Callum J, Lin Y, McCluskey S, Hallet J. Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons. J Gastrointest Surg 2016; 20:1106-22. [PMID: 27025709 DOI: 10.1007/s11605-016-3111-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/15/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery. METHODS We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders. RESULTS Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs. CONCLUSION Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.
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Affiliation(s)
| | - Natalie G Coburn
- Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robin S McLeod
- Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Emily Pearsall
- Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Francis S W Zih
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Julie Hallet
- Division of General Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Odette Cancer Centre-Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2-063, Toronto, M4N3M5, ON, Canada.
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Kagedan DJ, Raju RS, Dixon ME, Shin E, Li Q, Liu N, Elmi M, El-Sedfy A, Paszat L, Kiss A, Earle CC, Mittmann N, Coburn NG. The association of adjuvant therapy with survival at the population level following pancreatic adenocarcinoma resection. HPB (Oxford) 2016; 18:339-47. [PMID: 27037203 PMCID: PMC4814617 DOI: 10.1016/j.hpb.2015.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Using a retrospective observational cohort approach, the overall survival (OS) following curative-intent resection of pancreatic adenocarcinoma (PC) was defined at the population level according to adjuvant treatment, and predictors of OS were identified. METHODS Patients undergoing resection of PC in the province of Ontario between 2005 and 2010 were identified using the provincial cancer registry, and linked to databases that include all treatments received and outcomes experienced in the province. Pathology reports were abstracted for staging and margin status. Patients were identified as having received chemotherapy (CT), chemoradiation therapy (CRT), or no adjuvant treatment (NAT). Kaplan-Meier survival analysis of patients surviving ≥ 6 months was performed, and predictors of OS identified by log-rank test. Cox multivariable analysis was used to define independent predictors of OS. RESULTS Among the 473 patients undergoing PC resection, the median survival was 17.8 months; for the 397 who survived ≥ 6 months following surgery, the 5-year OS for the CT, CRT, and NAT groups was 21%, 16%, and 17%, respectively (p = 0.584). Lymph node-negative patients demonstrated improved OS associated with chemotherapy on multivariable analysis (HR = 2.20, 95% CI = 1.25-3.83 for NAT vs. CT). CONCLUSIONS Following PC resection, only patients with negative lymph nodes demonstrated improved OS associated with adjuvant chemotherapy.
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Affiliation(s)
- Daniel J. Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Matthew E. Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Elizabeth Shin
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ning Liu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Maryam Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Abraham El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Lawrence Paszat
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada,Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Craig C. Earle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada,Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Natalie G. Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada,Sunnybrook Health Sciences Centre, Toronto, ON, Canada,Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada,Correspondence Natalie Groce Coburn, 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada. Tel: +1 416 480 6916. Fax: +1 416 480 6002.
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Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford) 2015; 17:11-6. [PMID: 24750457 PMCID: PMC4266435 DOI: 10.1111/hpb.12265] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/09/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been shown to reduce hospital stay without compromising outcomes. Attempts to apply ERAS principles in the context of pancreatic surgery have generated encouraging results. A systematic review of the current evidence for ERAS following pancreatic surgery was conducted. METHODS A literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Library was performed for articles describing postoperative clinical pathways in pancreatic surgery during the years 2000-2013. The keywords 'clinical pathway', 'critical pathway', 'fast-track', 'pancreas' and 'surgery' and their synonyms were used as search terms. Articles were selected for inclusion based on predefined criteria and ranked for quality. Details of the ERAS protocols and relevant outcomes were extracted and analysed. RESULTS Ten articles describing an ERAS protocol in pancreatic surgery were identified. The level of evidence was graded as low to moderate. No articles reported an adverse effect of an ERAS protocol for pancreatic surgery on perioperative morbidity or mortality. Length of stay (LoS) was decreased and readmission rates were found to be unchanged in six of seven studies that compared these outcomes. CONCLUSIONS Evidence indicates that ERAS protocols may be implemented in pancreatic surgery without compromising patient safety or increasing LoS. Enhanced recovery after surgery programmes in the context of pancreatic surgery should be standardized based upon the best available evidence, and trials of ERAS programmes involving multiple centres should be performed.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of SurgeryToronto, ON, Canada
| | - Mahrosh Ahmed
- Department of Surgery, Princess Margaret Cancer Centre, University Health NetworkToronto, ON, Canada
| | - Katharine S Devitt
- Department of Surgery, Princess Margaret Cancer Centre, University Health NetworkToronto, ON, Canada
| | - Alice C Wei
- Department of Surgery, Princess Margaret Cancer Centre, University Health NetworkToronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of TorontoToronto, ON, Canada,Correspondence, Alice C. Wei, Division of General Surgery, 10EN-215, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada. Tel: + 1 416 340 4232. Fax: + 1 416 340 3808. E-mail:
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