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Xu K, Lin B, Collado L, Martin MC, Carlson SJ, Raffetto JD, McPhee JT. Predicting wound complications following lower extremity revascularization. J Vasc Surg 2024; 79:642-650.e2. [PMID: 37984755 DOI: 10.1016/j.jvs.2023.11.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE The aim of this study was to create a simple risk score to identify factors associated with wound complications after infrainguinal revascularization. METHODS The Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2021 to identify 22,114 patients undergoing elective open revascularization for peripheral arterial disease (claudication, rest pain, tissue loss) or peripheral aneurysm. Emergency and trauma cases were excluded. The data set was divided into a two-thirds derivation set and one-third validation set to create a risk prediction model. The primary end point was wound complication (wound dehiscence, superficial/deep wound surgical site infection). Eight independent risk factors for wound complications resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-11 points), and very high (>12 points). RESULTS The wound complication rate in the derivation data set was 9.7% (n = 1428). Predictors of wound complication included age ≤73 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46), body mass index ≥35 kg/m2 (OR, 1.99; 95% CI, 1.68-2.36), non-Hispanic White (vs others: OR, 1.48; 95% CI, 1.30-1.69), diabetes (OR, 1.23; 95% CI, 1.10-1.37), white blood cell count >9900/mm3 (OR, 1.18; 95% CI, 1.03-1.35), absence of coronary artery disease (OR, 1.27; 95% CI, 1.03-1.35), operative time >6 hours (OR, 1.20; 95% CI, 1.05-1.37), and undergoing a femoral endarterectomy in conjunction with bypass (OR, 1.34; 95% CI, 1.14-1.57). In both the derivation and validation sets, wound complications correlated with risk category. Among the defined categories in the derivation set, wound complication rates were 4.5% for low-risk patients, 8.5% for moderate-risk patients, 13.8% for high-risk patients, and 23.8% for very high-risk patients, with similar results for the internal validation data set. Operative indication did not independently associate with wound complications. Patients with wound complications had higher rates of reoperation and graft failure. CONCLUSIONS This risk prediction model uses easily obtainable clinical metrics that allow for informed discussion of wound complication risk for patients undergoing open infrainguinal revascularization.
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Affiliation(s)
- Ke Xu
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Brenda Lin
- Department of Surgery, Boston Medical Center, Boston, MA
| | | | - Michelle C Martin
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - Sarah J Carlson
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Joseph D Raffetto
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - James T McPhee
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Carlson SJ, Forsyth AM, Alfson DB, Martin MC, Raffetto JD, McPhee JT. Safety and Feasibility of Radial Arterial Access for Lower Extremity, Mesenteric, and Aneurysm-Adjunctive Interventions. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2020.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Background Portal vein aneurysms are rare dilations in the portal venous system, for which the etiology and pathophysiological consequences are poorly understood. Method We reviewed the existing literature as well as present a unique anecdotal case of a patient presenting with a very large portal vein aneurysm that was successfully managed conservatively and non-operatively without anticoagulation, with close follow-up and routine surveillance. Result The rising prevalence of abdominal imaging in clinical practice has increased rates of portal vein aneurysm detection. While asymptomatic aneurysms less than 3 cm can be clinically observed, surgical intervention may be necessary in large asymptomatic aneurysms (>3 cm) with or without thrombus, or small aneurysms with evidence of evolving mural thrombus formation on imaging. Conclusion Portal vein aneurysms present a diagnostic challenge for any surgeon, and the goal for surgical therapy is based on repairing the portal vein aneurysm, and if portal hypertension is present decompressing via surgically constructed shunts.
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Affiliation(s)
- Sameer A Hirji
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C Robertson
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sergio Casillas
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA
| | - James T McPhee
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Naren Gupta
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Michelle C Martin
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Joseph D Raffetto
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
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Madenci AL, Ozaki CK, Gupta N, Raffetto JD, Belkin M, McPhee JT. Perioperative outcomes of elective inflow revascularization for lower extremity claudication in the American College of Surgeons National Surgical Quality Improvement Program database. Am J Surg 2016; 212:461-467.e2. [DOI: 10.1016/j.amjsurg.2015.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/27/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Daniel VT, Gupta N, Raffetto JD, McPhee JT. Impact of coexisting aneurysms on open revascularization for aortoiliac occlusive disease. J Vasc Surg 2016; 63:944-8. [PMID: 26843353 DOI: 10.1016/j.jvs.2015.10.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 10/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined. METHODS The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition. RESULTS Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). The baseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P = .27) and congestive heart failure (6.6% vs 6.3%; P = .65) but differed by age (62.2 years vs 68.4 years; P < .0001) and hypertension (65.4% vs 69.1%; P = .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P = .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P < .0002), age >65 years age (OR, 3.1; 95% CI, 2.4-4.1; P < .0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P < .0001), and concurrent lower extremity revascularization (OR, 1.3; 95% CI, 1.1-1.7; P < .02). CONCLUSIONS Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.
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Affiliation(s)
- Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.
| | - Naren Gupta
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Joseph D Raffetto
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - James T McPhee
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Boston University School of Medicine, Boston, Mass
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Eslami MH, Rybin D, Doros G, McPhee JT, Farber A. Mortality of acute mesenteric ischemia remains unchanged despite significant increase in utilization of endovascular techniques. Vascular 2015; 24:44-52. [DOI: 10.1177/1708538115577730] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction In this study, we evaluated if increase in utilization of endovascular surgery has affected in-hospital mortality rates among patients with acute mesenteric ischemia. Methods The National Inpatient Sample (2003–2011) was queried for acute mesenteric ischemia using ICD-9 code for acute mesenteric ischemia (557.1). This cohort was divided into patients treated with open vascular surgery (open vascular group) and by endovascular therapies (endovascular group) based on the ICD-9CM procedure codes. Multivariable logistic regression was used to determine temporal trend for mortality while adjusting for confounding variables. Results There was 1.45-fold increase in utilization of endovascular techniques in this study. In-hospital mortality rate, total median charges and length of stay were significantly lower among the endovascular group than the open vascular group despite having significantly higher Elixhauser comorbidities index (3 ± 0.1 vs. 2.7 ± 0.1, p = .003). Over the course of the study period, there was no change in the overall mortality rate despite higher endovascular utilization. Factors associated with increased mortality included age, open surgical repair (Odds ratio: 1.45, 95% Confidence Interval: 1.10–1.91, p = .016) and bowel resection Odds ratio: 2.88, 95% Confidence Interval: 2.01–4.12). Conclusion The mortality rate for acute mesenteric ischemia remains unchanged throughout this contemporary study. Open surgical intervention, bowel resection and age were associated with increased mortality. Endovascular group patients had better survival despite higher morbidity indices.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston School of Public Health, Boston, MA, USA
| | - James T McPhee
- Division of Vascular Surgery, Boston VA Medical Center, West Roxbury, MA, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA, USA
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Gupta N, Moreira C, White S, Mattera S, Raffetto JD, Bhatt DL, Gaziano JM, McPhee JT. PS126. Vascular Surgeons Can Improve the Cardiovascular Health of Patients With Clinical Atherosclerotic Cardiovascular Disease by Implementing an Intensive Lipid-Lowering Regimen and Providing Smoke Cessation Counseling. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.144] [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: 11/24/2022]
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Ho KJ, Madenci AL, McPhee JT, Semel ME, Bafford RA, Nguyen LL, Ozaki CK, Belkin M. Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy. J Vasc Surg 2014; 59:1282-90. [DOI: 10.1016/j.jvs.2013.11.090] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/27/2013] [Accepted: 11/28/2013] [Indexed: 11/28/2022]
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Ozaki CK, Sobieszczyk PS, Ho KJ, McPhee JT, Gravereaux EC. Evidence-based carotid artery-based interventions for stroke risk reduction. Curr Probl Surg 2014; 51:198-242. [PMID: 24767101 DOI: 10.1067/j.cpsurg.2014.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
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Eslami MH, Rybin D, Doros G, McPhee JT, Farber A. Despite Advances and Incorporation of Endovascular Techniques, Mortality Rates for Patients with Acute Mesenteric Ischemia Remain Unchanged: Analysis of the Nationwide Inpatient Sample. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.07.096] [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: 10/26/2022]
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Thomas VM, Nguyen LL, Eslami MH, Kalish JA, Farber A, McPhee JT. Contemporary Comparison of Supra-Aortic Trunk Reconstructions for Occlusive Disease: Transthoracic Reconstructions Versus Extrathoracic Reconstructions. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.06.027] [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: 12/01/2022]
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McPhee JT, Nguyen LL, Ho KJ, Ozaki CK, Conte MS, Belkin M. Risk prediction of 30-day readmission after infrainguinal bypass for critical limb ischemia. J Vasc Surg 2013; 57:1481-8. [DOI: 10.1016/j.jvs.2012.11.074] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/09/2012] [Accepted: 11/14/2012] [Indexed: 11/25/2022]
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Baril DT, Patel VI, Judelson DR, Goodney PP, McPhee JT, Hevelone ND, Cronenwett JL, Schanzer A. Outcomes of lower extremity bypass performed for acute limb ischemia. J Vasc Surg 2013; 58:949-56. [PMID: 23714364 DOI: 10.1016/j.jvs.2013.04.036] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/09/2013] [Accepted: 04/14/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Acute limb ischemia remains one of the most challenging emergencies in vascular surgery. Historically, outcomes following interventions for acute limb ischemia have been associated with high rates of morbidity and mortality. The purpose of this study was to determine contemporary outcomes following lower extremity bypass performed for acute limb ischemia. METHODS All patients undergoing infrainguinal lower extremity bypass between 2003 and 2011 within hospitals comprising the Vascular Study Group of New England were identified. Patients were stratified according to whether or not the indication for lower extremity bypass was acute limb ischemia. Primary end points included bypass graft occlusion, major amputation, and mortality at 1 year postoperatively as determined by Kaplan-Meier life table analysis. Multivariable Cox proportional hazards models were constructed to evaluate independent predictors of mortality and major amputation at 1 year. RESULTS Of 5712 lower extremity bypass procedures, 323 (5.7%) were performed for acute limb ischemia. Patients undergoing lower extremity bypass for acute limb ischemia were similar in age (66 vs 67; P = .084) and sex (68% male vs 69% male; P = .617) compared with chronic ischemia patients, but were less likely to be on aspirin (63% vs 75%; P < .0001) or a statin (55% vs 68%; P < .0001). Patients with acute limb ischemia were more likely to be current smokers (49% vs 39%; P < .0001), to have had a prior ipsilateral bypass (33% vs 24%; P = .004) or a prior ipsilateral percutaneous intervention (41% vs 29%; P = .001). Bypasses performed for acute limb ischemia were longer in duration (270 vs 244 minutes; P = .007), had greater blood loss (363 vs 272 mL; P < .0001), and more commonly utilized prosthetic conduits (41% vs 33%; P = .003). Acute limb ischemia patients experienced increased in-hospital major adverse events (20% vs 12%; P < .0001) including myocardial infarction, congestive heart failure exacerbation, deterioration in renal function, and respiratory complications. Patients who underwent lower extremity bypass for acute limb ischemia had no difference in rates of graft occlusion (18.1% vs 18.5%; P = .77), but did have significantly higher rates of limb loss (22.4% vs 9.7%; P < .0001) and mortality (20.9% vs 13.1%; P < .0001) at 1 year. On multivariable analysis, acute limb ischemia was an independent predictor of both major amputation (hazard ratio, 2.16; confidence interval, 1.38-3.40; P = .001) and mortality (hazard ratio, 1.41; confidence interval, 1.09-1.83; P = .009) at 1 year. CONCLUSIONS Patients who present with acute limb ischemia represent a less medically optimized subgroup within the population of patients undergoing lower extremity bypass. These patients may be expected to have more complex operations followed by increased rates of perioperative adverse events. Additionally, despite equivalent graft patency rates, patients undergoing lower extremity bypass for acute ischemia have significantly higher rates of major amputation and mortality at 1 year.
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Affiliation(s)
- Donald T Baril
- University of Massachusetts Medical Center, Worcester, Mass.
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Madenci AL, Ozaki CK, Belkin M, McPhee JT. Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era. J Vasc Surg 2013; 57:1275-1282.e2. [DOI: 10.1016/j.jvs.2012.11.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 11/05/2012] [Accepted: 11/08/2012] [Indexed: 11/28/2022]
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Ho KJ, Madenci AL, McPhee JT, Semel ME, Nguyen LL, Ozaki C, Belkin M. Predictors and Consequences of Unplanned Hospital Readmission Within 30 Days of Carotid Endarterectomy. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.02.085] [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: 10/26/2022]
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Madenci AL, McPhee JT, Menard MT. Carotid Artery Stenting (CAS) Associated With Increased Mortality Compared With Carotid Endarterectomy (CEA) in the NSQIP Database, 2011. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.02.174] [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: 11/24/2022]
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McPhee JT, Barshes NR, Ho KJ, Madenci A, Ozaki CK, Nguyen LL, Belkin M. Predictive factors of 30-day unplanned readmission after lower extremity bypass. J Vasc Surg 2013; 57:955-62. [DOI: 10.1016/j.jvs.2012.09.077] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/26/2012] [Accepted: 09/28/2012] [Indexed: 10/27/2022]
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Baril DT, Patel VI, Judelson DR, Goodney PP, McPhee JT, Prushik SG, Hevelone N, Cronenwett JL, Schanzer A. Outcomes of Lower Extremity Bypass Performed for Acute Limb Ischemia. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2012.11.031] [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: 11/17/2022]
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Madenci AL, Ozaki CK, Belkin M, McPhee JT. Carotid-Subclavian Bypass and Subclavian-Carotid Transposition in the TEVAR Era. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.10.020] [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: 10/27/2022]
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McPhee JT, Nguyen LL, Ho KJ, Ozaki CK, Conte MS, Belkin M. Thirty-Day Readmission Following Lower Extremity Bypass for Critical Limb Ischemia (CLI) in the PREVENT III Cohort. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.08.083] [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: 11/27/2022]
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McPhee JT, Ho KJ, Lopez J, Glynn R, Belkin M, Menard MT. RR3. Protamine Sulfate Use Does Not Lower Hemorrhagic Complications in Lower Extremity Bypass (LEB). J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.03.212] [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: 11/30/2022]
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McPhee JT, Barshes NR, Ozaki CK, Nguyen LL, Belkin M. Optimal conduit choice in the absence of single-segment great saphenous vein for below-knee popliteal bypass. J Vasc Surg 2012; 55:1008-14. [PMID: 22365176 DOI: 10.1016/j.jvs.2011.11.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Single-segment great saphenous vein (SSGSV) remains the conduit of choice for femoral to below-knee popliteal (F-BK) surgical revascularization. The purpose of this study was to determine the optimal conduit in patients with inadequate SSGSV. METHODS This was a retrospective review of a prospectively maintained vascular registry. Patients underwent F-BK bypass with alternative vein (AV; arm vein, spliced GSV, or composite vein) or prosthetic conduit (PC). RESULTS From January 1995 to June 2010, 83 patients had unusable SSGSV for F-BK popliteal reconstruction. Thirty-three patients had an AV conduit and 50 had PC. The AV group was a lower median age than the PC group (69 vs 75 years). The two groups were otherwise similar in comorbid conditions of diabetes mellitus (57.6% vs 58.0%; P > .99), smoking (15.2% vs 32.0%; P = .12), and hemodialysis (3% vs 12%; P = .23). The groups were similar in baseline characteristics such as limb salvage as indication (93.9% vs 86.0%; P = .31), mean runoff score (5.2 vs 4.6; P = .39), and prior ipsilateral bypass attempts (18.2% vs 18.0%; P > .99). The AV and PC groups were also similar in 30-day mortality (6.1% vs 4.0%; P > .99) and wound infection rates (6.1% vs 6.0%; P > .99). PC patients were more likely to be discharged on Coumadin (Bristol-Myers Squibb, Princeton, NJ) than AV patients (62.0% vs 27.3%; P = .002). Seventeen of the 50 PC patients (34%) had a distal anastomotic vein cuff. A log-rank test comparison of 5-year outcomes for the AV and PC groups found no significant difference in primary patency (55.3% ± 9.9% vs 51.9% ± 10.8%; P = .82), assisted primary patency (68.8% ± 9.6% vs 54.0% ± 11.0%; P = .45), secondary patency (68.4% ± 9.6% vs 63.7% ± 10.4% for PC; P = .82), or limb salvage rates (96.2% ± 3.8% vs 81.1% ± 8.1%; P = .19). Multivariable analysis demonstrated no association between conduit type and loss of patency or limb. The factors most predictive of primary patency loss were limb salvage as the indication for surgery (hazard ratio [HR], 4.23; 95% confidence interval [CI], 1.65-10.9; P = .003) and current hemodialysis (HR, 3.51; 95% CI, 1.08-11.4; P = .037). The most predictive factor of limb loss was current hemodialysis (HR, 7.02; 95% CI, 1.13-43.4; P = .036). CONCLUSIONS For patients with inadequate SSGSV, PCs, with varying degrees of medical and surgical adjuncts, appear comparable to AV sources in graft patency for below-knee popliteal bypass targets. This observation is tempered by the small cohort sample size of this single-institutional analysis. Critical limb ischemia as the operative indication and current hemodialysis predict impaired patency, and hemodialysis is associated with limb loss.
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Affiliation(s)
- James T McPhee
- Brigham and Women’s Hospital, Division of Vascular and Endovascular Surgery, 75 Francis St, Boston, MA 02155, USA.
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McPhee JT, Soybel DI, Oram RK, Belkin M. Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak. J Vasc Surg 2011; 54:1164-6. [DOI: 10.1016/j.jvs.2011.04.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 11/29/2022]
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McPhee JT, Menard MT. Current management approach for left renal vein entrapment syndrome: the so-called ‘Nutcracker’ syndrome. Interv Cardiol 2011. [DOI: 10.2217/ica.11.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Eslami MH, McPhee JT, Simons JP, Schanzer A, Messina LM. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 2011; 53:307-15. [DOI: 10.1016/j.jvs.2010.08.080] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/26/2010] [Accepted: 08/26/2010] [Indexed: 10/18/2022]
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McPhee JT, Robinson WP, Eslami MH, Arous EJ, Messina LM, Schanzer A. Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. J Vasc Surg 2010; 53:591-599.e2. [PMID: 21144692 DOI: 10.1016/j.jvs.2010.09.063] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 09/17/2010] [Accepted: 09/27/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Studies analyzing the effects of volume on outcomes after abdominal aortic aneurysm (AAA) repair have primarily centered on institutional volume and not on individual surgeon volume. We sought to determine the relative effects of both surgeon and institution volume on mortality after open and endovascular aneurysm repair (EVAR) for intact AAAs. METHODS The Nationwide Inpatient Sample (2003-2007) was queried to identify all patients undergoing open repair and EVAR for nonruptured AAAs. To calculate surgeon and institution volume, 11 participating states that record a unique physician identifier for each procedure were included. Surgeon and institution volume were defined as low (first quintile), medium (second, third, or fourth quintile), and high (fifth quintile). Stratification by institution volume and then by surgeon volume was performed to analyze the primary endpoint: in-hospital mortality. Multivariable models were used to evaluate the association of institution and surgeon volume with mortality for open repair and EVAR, controlling for potential confounders. RESULTS During the study period, 5972 open repairs and 8121 EVARs were performed. For open AAA repair, a significant mortality reduction was associated with both annual institution volume (low <7, medium 7-30, and high >30) and surgeon volume (low ≤ 2, medium 3-9, and high >9). High surgeon volume conferred a greater mortality reduction than did high institution volume. When low and medium volume institutions were stratified by surgeon volume, mortality after open AAA repair was inversely proportional to surgeon volume (8.7%, 3.6%, and 0%; P < .0001, for low, medium, and high-volume surgeons at low-volume institutions; and 6.7%, 4.8%, and 3.3%; P = .02, for low, medium, and high-volume surgeons at medium-volume institutions). High-volume institutions stratified by surgeon volume demonstrated the same trend (5.1%, 3.4%, and 2.8%), but this finding was not statistically significant (P = .57). Multivariable analysis was confirmatory: low surgeon volume independently predicted mortality (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.1; P < .001); low institution volume did not (P = .1). For EVAR, neither institution volume nor surgeon volume influenced mortality (univariate or multivariable). CONCLUSION The primary factor driving the mortality reduction associated with case volume after open AAA repair is surgeon volume, not institution volume. Regionalization of AAAs should focus on open repair, as EVAR outcomes are equivalent across volume levels. Payers may need to re-evaluate strategies that encourage open AAA repair at high-volume institutions if specific surgeon volume is not considered.
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Affiliation(s)
- James T McPhee
- Department of Surgery, University of Massachusetts Medical School, Worcester, Mass 01655, USA
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McPhee JT, Robinson WP, Eslami MH, Arous EJ, Messina LM, Schanzer A. Surgeon Case Volume, Not Institution Case Volume, Is the Primary Determinant of In-Hospital Mortality After Elective Open Abdominal Aortic Aneurysm Repair (AAA). J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2010.06.118] [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: 11/26/2022]
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Carroll JE, Hurwitz ZM, Simons JP, McPhee JT, Ng SC, Shah SA, Al-Refaie WB, Tseng JF. In-hospital mortality after resection of biliary tract cancer in the United States. HPB (Oxford) 2010; 12:62-7. [PMID: 20495647 PMCID: PMC2814406 DOI: 10.1111/j.1477-2574.2009.00129.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [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: 06/16/2009] [Accepted: 08/24/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess perioperative mortality following resection of biliary tract cancer within the U.S. BACKGROUND Resection remains the only curative treatment for biliary tract cancer. However, current data on operative mortality after surgical resections for biliary tract cancer are limited to small and single-center studies. METHODS Using the Nationwide Inpatient Sample 1998-2006, a cohort of patient-discharges was assembled with a diagnosis of biliary tract cancer, including intrahepatic bile duct, extrahepatic bile duct, and gall bladder cancers. Patients undergoing resection, including hepatic resection, bile duct resection, pancreaticoduodenectomy, and cholecystectomy, were retained. The primary outcome measure was in-hospital mortality. Categorical variables were analyzed by chi-square. Multivariable logistic regression was performed to identify independent predictors of in-hospital mortality following resection. RESULTS 31 870 patient-discharges occurred for the diagnosis of biliary tract cancer, including 36.2% intrahepatic ductal, 26.7% extrahepatic ductal, and 31.1% gall bladder. Of the total, 18.6% underwent resection: mean age was 69.3 years (median 70.0); 60.8% were female; 73.7% were white. Overall inpatient surgical mortality was 5.6%. Independently predictive factors of mortality included patient age >/=50 (vs. <50; age 50-59 odds ratio [OR] 5.51, 95% confidence interval [CI] 1.70-17.93; age 60-69 OR 7.25, 95% CI 2.29-22.96; age >/= 70 OR 9.03, 95% CI 2.86-28.56), the presence of identified comorbidities (congestive heart failure, OR 3.67, 95% CI 2.61-5.16; renal failure, OR 4.72, 95% CI 2.97-7.49), and admission designated as emergent (vs. elective; OR 1.82, 95% CI 1.39-2.37). CONCLUSION Increased in-hospital mortality for patients undergoing biliary tract cancer resection corresponded to age, comorbidity, hospital volume, and emergent admission. Further study is warranted to utilize these observations in promoting early detection, diagnosis, and elective resection.
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Affiliation(s)
- James E Carroll
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - Zachary M Hurwitz
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - Jessica P Simons
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - James T McPhee
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - Sing Chau Ng
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - Shimul A Shah
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
| | - Waddah B Al-Refaie
- Division of Surgical Oncology, University of Minnesota Medical Center and Minneapolis Veteran Affairs Medical CenterMinneapolis, MN, USA
| | - Jennifer F Tseng
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical SchoolWorcester, MA
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Simons JP, McPhee JT, Messina LM, Schanzer A, Eslami MH. Despite Higher Utilization of Carotid Angioplasty and Stenting (CAS) in 2006, Postprocedure Stroke, Mortality Rates, Hospital Charges, and Discharges to Nursing Skilled Facilities Remain Higher for CAS than for Carotid Endarterectomy Compared with 2005. J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2009.10.075] [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: 11/24/2022]
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Abstract
BACKGROUND Total pancreatectomy (TP) is performed for various indications. Historically, morbidity and mortality have been high. Recent series reporting improved peri-operative mortality have renewed interest in TP. We performed a national review of TP including indication, patient/hospital characteristics, complications and peri-operative mortality. METHODS The Nationwide Inpatient Sample (NIS) was queried to identify TPs performed during 1998 to 2006. Univariate analyses were used to compare patient/hospital characteristics. Multivariable logistic regression was performed to identify predictors of in-hospital mortality. Post-operative complications/disposition were assessed. RESULTS From 1998 to 2006, 4013 weighted patient-discharges occurred for TP. Fifty-three per cent were male; mean age 58 years. INDICATION neoplastic disease 67.8%. Post-operative complications occurred in 28%. Univariate analyses: TPs increased significantly (1998, n = 384 vs. 2006 n = 494, P < 0.01). 77.1% of TPs occurred in teaching hospitals (P < 0.0001), 86.4% in hospitals performing <five pancreatectomies/year (P < 0.0001). In-patient mortality was 8.5% with a significant decrease (12.4% 1998-2000 vs. 5.9% 2002-2006, P < 0.01). Multivariable analyses: advanced age [referent < or = 50 years; > or = 70 Adjusted odds ratio (AOR) 3.4, 95% confidence interval (CI) 1.33-8.67], select patient comorbidities and year (referent = 2004-2006; 1998-2000 AOR 2.70; 95% CI 1.41-5.14) independently predicted in-patient mortality whereas hospital surgical volume did not. DISCUSSION TP is increasingly performed nationwide with a concomitant decrease in peri-operative mortality. Patient characteristics, rather than hospital volume, predicted increased mortality.
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Affiliation(s)
- Melissa M Murphy
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Hill JS, McPhee JT, Whalen GF, Sullivan ME, Warshaw AL, Tseng JF. In-hospital mortality after pancreatic resection for chronic pancreatitis: population-based estimates from the nationwide inpatient sample. J Am Coll Surg 2009; 209:468-76. [PMID: 19801320 DOI: 10.1016/j.jamcollsurg.2009.05.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 05/27/2009] [Accepted: 05/27/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic resection can be performed to ameliorate the sequelae of chronic pancreatitis in selected patients. The perceived risk of pancreatectomy may limit its use. Using a national database, this study compared mortality after pancreatic resections for chronic pancreatitis with those performed for neoplasm. STUDY DESIGN Patient discharges with chronic pancreatitis or pancreatic neoplasm were queried from the Nationwide Inpatient Sample, 1998 to 2006. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. RESULTS There were 11,048 pancreatic resections. Malignant neoplasms represented 64.2% of the sample; benign neoplasms and pancreatitis comprised 17.1% and 18.7%, respectively. In-hospital mortality rates were 2.2% and 1.7% for the pancreatitis and benign tumor cohorts, respectively, compared with 5.9% for the malignancy cohort (overall p < 0.01). A multivariable logistic regression examined differences in mortality among diagnoses while adjusting for patient and hospital characteristics; covariates included patient gender, race, age, comorbidities, type of pancreatectomy, payor, hospital teaching status, hospital size, and hospital volume. After adjustment, patients undergoing resection for pancreatitis were at a significantly lower risk of in-hospital mortality when compared with those with malignant neoplasm (odds ratio, 0.43; 95% CI, 0.28 to 0.67). CONCLUSIONS Pancreatectomies for chronic pancreatitis have lower in-hospital mortality than those performed for malignancy and similar rates as resection for benign tumors. Pancreatic resection, which can improve quality of life in chronic pancreatitis patients, can be performed with moderate mortality rates and should be considered in appropriate patients.
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Affiliation(s)
- Joshua S Hill
- Department of Surgery, Surgical Outcomes Analysis and Research, University of Massachusetts Medical School, 55 Lake Avenue, Worcester, MA 01655, USA
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Abstract
OBJECTIVE Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies, which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level. METHODS Using the Nationwide Inpatient Sample, discharge records with surgeon identifiers for all nontrauma PR (n = 3581) were examined from 1998 to 2005. Surgeons were divided into 2 groups: (HV; > or = 5 operations/year) or low volume (LV; <5 operations/year). We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient and hospital factors. To further eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores. RESULTS One hundred thirty-four HV and 1450 LV surgeons performed 3581 PR in 742 hospitals across 12 states that reported surgeon identifier information over the 8-year period. Patients who underwent PR by HV surgeons were more likely to be male, white raced, and a resident of a high-income zip code (P < 0.05). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance, and surgery by HV surgeon. HV surgeons had a lower adjusted mortality compared with LV surgeons (2.4% vs. 6.4%; P < 0.0001). CONCLUSIONS After controlling for patient demographics and factors, pancreatic resection by a HV surgeon in this case-controlled cohort was independently associated with a 51% reduction in in-hospital mortality.
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Affiliation(s)
- Robert W Eppsteiner
- Department of Surgery, Surgical Outcomes Analysis, and Research, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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Hill JS, McPhee JT, McDade TP, Zhou Z, Sullivan ME, Whalen GF, Tseng JF. Pancreatic neuroendocrine tumors: the impact of surgical resection on survival. Cancer 2009; 115:741-51. [PMID: 19130464 DOI: 10.1002/cncr.24065] [Citation(s) in RCA: 241] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although surgical resection is generally recommended for patients with localized pancreatic neuroendocrine tumors (PNETs), the impact of resection on overall survival is unknown. The authors investigated the survival advantage of pancreatic resection using a national database. METHODS This is a retrospective survival analysis of patients with PNETs from the Surveillance, Epidemiology, and End Results database (1988-2002). RESULTS A total of 728 patients with PNETs were identified with a median survival of 43 months using Kaplan-Meier survival methods. Resection of tumor was associated with significantly improved survival compared with those patients who were recommended for but did not undergo resection (114 months vs 35 months; P < .0001). This survival benefit was demonstrated for patients with localized, regional, and metastatic disease. A multivariable Cox proportional hazards model was constructed to assess the overall effect of surgical resection on survival, and demonstrated an adjusted odds ratio of 0.48 (95% confidence interval, 0.35-0.66) compared with those who were recommended for surgery but did not proceed to surgery. CONCLUSIONS The authors have demonstrated in a large national study that resection of primary tumor in patients with PNETs is associated with improved survival across all disease stages. Patients with localized, regional, and metastatic PNETs who are reasonable operative candidates should be considered for resection of their primary tumors.
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Affiliation(s)
- Joshua S Hill
- Department of Surgery, Surgical Outcomes Analysis and Research, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA
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Cooley EK, McPhee JT, Simons JP, Sweeney WB, Tseng JF, Alavi K. Colorectal neoplasia screening before age 50?: current epidemiologic trends in the United States. Dis Colon Rectum 2009; 52:222-9. [PMID: 19279416 DOI: 10.1007/dcr.0b013e31819a3f07] [Citation(s) in RCA: 12] [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] [Indexed: 02/08/2023]
Abstract
PURPOSE Colorectal cancer screening has decreased mortality through early disease detection. In 1995, the United States Preventative Services Task Force recommended commencing screening at age 50 for average-risk people. We assessed trends in colorectal resection for neoplasia in the interval following these recommendations. METHODS The Nationwide Inpatient Sample was queried to identify patient discharges for colorectal resection of neoplastic disease, 1998-2005. Univariate analyses were performed using Rao-Scott chi-squared tests and survey-weighted analysis of variance. Trends were analyzed by the Mantel-Haenszel chi-squared test. RESULTS There were 212,389 patient discharges following resection for colorectal neoplasia. The number of resections for each age group were as follows: less than 50 years ranged from 11.8 to 13.3 percent, around 12.5 percent for ages 50 to 70 years, and 13.5 to 11.6 percent for ages greater than 70, with overall P < 0.0001. In-hospital mortality was 0.6 percent for patients aged less than 50 years, 1.5 percent for those aged 50 to 70 years, and 4.6 percent for those aged greater than 70 years. Right colectomy was the most common procedure among all age groups (42.5 percent). CONCLUSIONS Although the national incidence of colorectal cancer has been fairly stable, the increase in colorectal resection for neoplasia in patients less than age 50, combined with their low in-hospital mortality rate, strengthens the argument for screening before age 50. The predominance of right-sided procedures supports the use of full colonoscopy as the primary screening method.
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Affiliation(s)
- Erin K Cooley
- Department of Surgery, University of Massachusetts Medical School, Surgical Outcomes Analysis and Research, Worcester, Massachusetts, USA
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McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008; 48:1442-50, 1450.e1. [PMID: 18829236 DOI: 10.1016/j.jvs.2008.07.017] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. METHODS All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality. RESULTS During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05). CONCLUSIONS Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.
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Affiliation(s)
- James T McPhee
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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Hill JS, McPhee JT, Messina LM, Ciocca RG, Eslami MH. Regionalization of abdominal aortic aneurysm repair: evidence of a shift to high-volume centers in the endovascular era. J Vasc Surg 2008; 48:29-36. [PMID: 18589227 DOI: 10.1016/j.jvs.2008.02.048] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 02/13/2008] [Accepted: 02/19/2008] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Since the early 1990s, many studies have shown lower mortality for abdominal aortic aneurysm (AAA) repair at high-volume centers compared with low-volume centers. The introduction of endovascular AAA repair (EVAR) also has changed the practice of AAA repair. The goal of this study was to determine if regionalization of AAA repair occurred in the United States. Etiologic factors were examined in addition to any reduction in operative mortality rates. METHODS Patient discharges of nonruptured AAA repair were identified from the Nationwide Inpatient Sample between 1998 and 2004. Hospitals were stratified by yearly AAA surgical volume of low (< or =17 cases), medium (18 to 50), and high (>50). RESULTS A total of 46,901 patients underwent AAA repair (72.7% open vs 27.3% endovascular). The percentage of AAA repairs performed at both low-volume (36.2% to 24.3%) and medium-volume (51.0% to 44.8%) centers fell; whereas, the percentage performed at high-volume centers nearly tripled (12.9% vs 30.9%). In 1998 there were 10 high-volume centers; by 2004 this had increased to 26. The number of low-volume centers decreased, from 412 to 328. EVAR was more rapidly adopted by high-volume centers compared with low-volume centers. By 2004, 64.3% of AAA repairs at high-volume centers were done with endovascular techniques compared with 31.8% in low-volume centers. A concurrent reduction occurred in patient mortality, from 4.4% in 1998 to 2.5% in 2004 (P < .0001). CONCLUSION Between 1998 and 2004, a trend towards the regionalization of AAA repair to high-volume centers occurred. Nearly one-third of all AAA repairs were performed at high-volume centers. There was a concurrent increase in the frequency of endovascular AAA repair, especially at high-volume centers. During this period of regionalization of AAA repair to high-volume centers, patient mortality after AAA repair decreased by 23%. Thus, the observed regionalization of AAA repair and the reduction in short-term patient mortality for this operation may be explained by increased utilization of endovascular technologies at high-volume centers.
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Affiliation(s)
- Joshua S Hill
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
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Abstract
OBJECTIVE To analyze in-hospital mortality after pancreatectomy using a large national database. SUMMARY AND BACKGROUND DATA Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm. METHODS A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by chi. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions. RESULTS In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P < 0.0001). Resections done at low (<5 procedures/year)- and medium (5-18/year)-volume centers had higher mortality compared with those at high (>18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3-4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5-3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test. CONCLUSIONS This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.
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Affiliation(s)
- James T McPhee
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01605, USA
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Smith JK, McPhee JT, Hill JS, Whalen GF, Sullivan ME, Litwin DE, Anderson FA, Tseng JF. National Outcomes After Gastric Resection for Neoplasm. ACTA ACUST UNITED AC 2007; 142:387-93. [PMID: 17441293 DOI: 10.1001/archsurg.142.4.387] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS That factors affecting outcomes of surgical resection in the treatment of gastric cancer can be identified using a large US database. DESIGN Retrospective observational study. SETTING The Nationwide Inpatient Sample from January 1, 1998, through December 31, 2003. PATIENTS We included 13 354 patient discharges (approximately 66 096 nationally by weighted analysis) who underwent gastric resection for neoplasm. MAIN OUTCOME MEASURE In-hospital mortality. Univariate analyses were performed by means of chi(2) tests. A multivariate logistic regression was performed to determine which variables were independently predictive of in-hospital mortality. RESULTS During the study period, 50 738 patients (approximately 250 420 nationally) were discharged with the diagnosis of gastric neoplasm. Of those, 13 354 (26.3%) underwent gastric resection during their hospitalization. In-hospital mortality for patients undergoing surgery was 6.0%, without significant change from 1998 through 2003. Factors predictive of significantly increased in-hospital mortality included low annual hospital surgical volume (lowest [<or= 4 gastrectomies per year] vs highest [>or= 11 gastrectomies per year], 6.8% vs 4.9%; adjusted odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8]), older patient age (50-69 vs <50 years, 4.0% vs 2.1%; adjusted OR, 1.5; 95% CI, 1.1-2.2) (>or =70 vs <50 years, 8.6% vs 2.1%; adjusted OR, 2.9; 95% CI, 2.0-4.3), male sex (male vs female, 6.7% vs 5.0%; adjusted OR, 1.3; 95% CI, 1.1-1.5), and procedure type (total gastrectomy vs all other resections, 8.0% vs 5.3%; adjusted OR, 1.4; 95% CI, 1.2-1.7). CONCLUSIONS Higher annual surgical volume is predictive of lower in-hospital mortality for patients undergoing gastric resection for neoplasm. Other factors significantly associated with superior outcomes after gastric resection included diagnosis type, procedure type, younger age, female sex, and fewer comorbid conditions.
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Affiliation(s)
- Jillian K Smith
- Department of Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, Worchester, MA 01605, USA
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McPhee JT, Asham EH, Rohrer MJ, Singh MJ, Wong G, Vorhies RW, Nelson PR, Cutler BS. The Midterm Results of Stent Graft Treatment of Thoracic Aortic Injuries. J Surg Res 2007; 138:181-8. [PMID: 17292414 DOI: 10.1016/j.jss.2006.09.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [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: 01/09/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.
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MESH Headings
- Accidents, Traffic/mortality
- Adult
- Aged
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/mortality
- Aneurysm, False/surgery
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/surgery
- Blood Vessel Prosthesis
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Postoperative Complications/mortality
- Retrospective Studies
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- James T McPhee
- Division of Vascular Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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Abstract
Assessing the impact of disease and treatment of the emotional state and temperament of preschool children has been limited by the lack of sensitive and objective measurement techniques. To construct such a measure for longitudinal use, a sample of 179 children with febrile seizures and 85 normal children were used to develop the Minnesota Preschool Affect Rating Scales (MN-PARS). Video-taped play sessions were a source of behaviorally anchored ratings on 12 scales. Factor analysis yielded three factors of Negative Affect, Positive Affect, and Self-regulation with additional individual scales of Dependency and Activity Level. These scales and factors yield reliable ratings, as measured by interrater agreement and split-half techniques, as well as initial evidence of concurrent validity. Although they were developed for measuring the behavioral effects of phenobarbital on children with febrile seizures, these scales provide an objective means of measuring emotional expression and self-regulation useful for other studies.
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Affiliation(s)
- E G Shapiro
- Division of Pediatric Neurology, University of Minnesota, Minneapolis 55455
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