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Maskal SM, Thomas JD, Miller BT, Fafaj A, Zolin SJ, Montelione K, Ellis RC, Prabhu AS, Krpata DM, Beffa LRA, Costanzo A, Zheng X, Rosenblatt S, Rosen MJ, Petro CC. Corrigendum to: Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial '175(3):813-821.'. Surgery 2024:S0039-6060(24)00124-7. [PMID: 38503603 DOI: 10.1016/j.surg.2024.03.002] [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] [Indexed: 03/21/2024]
Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Aldo Fafaj
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH
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Maskal SM, Thomas JD, Miller BT, Fafaj A, Zolin SJ, Montelione K, Ellis RC, Prabhu AS, Krpata DM, Beffa LRA, Costanzo A, Zheng X, Rosenblatt S, Rosen MJ, Petro CC. Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial. Surgery 2024; 175:813-821. [PMID: 37770344 DOI: 10.1016/j.surg.2023.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/27/2023] [Revised: 05/14/2023] [Accepted: 06/18/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days. METHODS This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications. RESULTS A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days. CONCLUSION Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.
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Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Aldo Fafaj
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | - Ajita S Prabhu
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/aprabhumd1
| | - David M Krpata
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/DKrpataMD
| | - Lucas R A Beffa
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/BeffaLukeMD
| | | | | | | | - Michael J Rosen
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/MikeRosen
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Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosenblatt S, Rosen S, Thompson R, Fafaj A, Thomas JD, Huang LC, Rosen MJ. Long-term Clinical and Patient-Reported Outcomes After Transversus Abdominis Release With Permanent Synthetic Mesh: A Single Center Analysis of 1203 Patients. Ann Surg 2023; 277:e900-e906. [PMID: 35793810 DOI: 10.1097/sla.0000000000005443] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 11/26/2022]
Abstract
OBJECTIVE We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice. SUMMARY BACKGROUND DATA Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain. METHODS Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain. RESULTS A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52-67], median body mass index was 32 kg/m 2 (IQR: 28-36), median hernia width was 15 cm (IQR: 12-19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1-4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement. CONCLUSIONS TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life.
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Affiliation(s)
- Samuel J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Steven Rosenblatt
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Samantha Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Reid Thompson
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jonah D Thomas
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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Fafaj A, Lo Menzo E, Alaedeen D, Petro CC, Rosenblatt S, Szomstein S, Massier C, Prabhu AS, Krpata DM, Cha W, Montelione K, Tastaldi L, Alkhatib H, Zolin SJ, Okida LF, Rosen MJ. Effect of Intraoperative Urinary Catheter Use on Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair: A Randomized Clinical Trial. JAMA Surg 2022; 157:667-674. [PMID: 35704302 PMCID: PMC9201739 DOI: 10.1001/jamasurg.2022.2205] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking. Objective To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair. Design, Setting, and Participants This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention. Interventions Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement. Main Outcomes and Measures PUR rate. Results Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement. Conclusions and Relevance Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered. Trial Registration ClinicalTrials.gov Identifier: NCT03835351.
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Affiliation(s)
- Aldo Fafaj
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Emanuele Lo Menzo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Diya Alaedeen
- Department of General Surgery, Fairview Hospital, Cleveland, Ohio
| | - Clayton C. Petro
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samuel Szomstein
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Christian Massier
- Department of General Surgery, Marymount Hospital, Garfield Heights, Ohio
| | - Ajita S. Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Walter Cha
- Department of General Surgery, Hillcrest Hospital, Mayfield Heights, Ohio
| | - Katherine Montelione
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luciano Tastaldi
- Department of General Surgery, University of Texas Medical Branch, Galveston
| | - Hemasat Alkhatib
- Department of General Surgery, MetroHealth System, Cleveland, Ohio
| | - Samuel J. Zolin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luis Felipe Okida
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Michael J. Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
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Blake KE, Zolin SJ, Tu C, Baier KF, Beffa LR, Alaedeen D, Krpata DM, Prabhu AS, Rosen MJ, Petro CC. Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial. Trials 2022; 23:616. [PMID: 35907909 PMCID: PMC9338471 DOI: 10.1186/s13063-022-06571-8] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy. METHODS This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention. DISCUSSION This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned. TRIAL REGISTRATION ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.
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Affiliation(s)
- K E Blake
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA.
| | - S J Zolin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - C Tu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - K F Baier
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - L R Beffa
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - D Alaedeen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
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Romero-Velez G, Burneikis T, Zolin SJ, Noureldine SI, Jin J, Berber E, Krishnamurthy VD, Shin J, Siperstein A. Quantifying disease-specific symptom improvement after parathyroid and thyroid surgery using patient-reported outcome measures. Am J Surg 2022; 224:923-927. [DOI: 10.1016/j.amjsurg.2022.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/27/2022]
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Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosen SH, Thompson RD, Fafaj A, Thomas JD, Huang LC, Rosen MJ. No Winning in the Battle of the Bulge: Hernia Recurrence after Abdominal Wall Reconstruction. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.180] [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: 11/25/2022]
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Thomas JD, Petro CC, Montelione KC, Zolin SJ, Krpata DM, Tu C, Rosen MJ, Prabhu AS. Laparoscopic vs Robotic Ventral Hernia Repair: 1-Year Postoperative Outcomes from the PROVE-IT Trial. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.144] [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: 12/01/2022]
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Zolin SJ, Rosen MJ. Failure of Abdominal Wall Closure: Prevention and Management. Surg Clin North Am 2021; 101:875-888. [PMID: 34537149 DOI: 10.1016/j.suc.2021.07.001] [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: 12/01/2022]
Abstract
This article reviews evidence-based techniques for abdominal closure and management strategies when abdominal wall closures fail. In particular, optimal primary fascial closure techniques, the role of prophylactic mesh, considerations for combined hernia repair, closure techniques when the fascia cannot be closed primarily, and management approaches for fascial dehiscence are reviewed.
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Affiliation(s)
- Samuel J Zolin
- Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH 44195, USA.
| | - Michael J Rosen
- Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH 44195, USA
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Naples R, Thomas JD, Monteiro R, Zolin SJ, Timmerman CK, Crawford K, Jin J, Shin JJ, Krishnamurthy VD, Berber E, Siperstein AE. Preoperative calcium and parathyroid hormone values are poor predictors of gland volume and multigland disease in primary hyperparathyroidism: A review of 2,000 consecutive patients. Endocr Pract 2021; 28:77-82. [PMID: 34403781 DOI: 10.1016/j.eprac.2021.08.003] [Citation(s) in RCA: 3] [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: 05/12/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Calcium and parathyroid hormone (PTH) values are thought to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values are correlated with operative findings to determine their utility in predicting gland involvement at parathyroid exploration. METHODS Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a four-gland exploration. Relationships between preoperative calcium and PTH values with per patient total gland volume were examined and stratified by number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was poor correlation between preoperative calcium and PTH (R=0.37), and both correlated poorly with total gland volume (R<0.40). Subgroup analysis by the number of involved glands similarly showed poor correlation. Mean total gland volume was similar among all subgroups (SA=1.28, DA=1.43, H=1.27 cc, p=0.52), implying individual glands were smaller in multigland disease. SA was found in 53% of patients with calcium ≤10.5 mg/dL and 78% if ≥12 mg/dL (p<0.001). CONCLUSION This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.
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Affiliation(s)
- Robert Naples
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Jonah D Thomas
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Rosebel Monteiro
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Samuel J Zolin
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Kate Crawford
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Judy Jin
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Joyce J Shin
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
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Perlmutter BC, Alkhatib H, Lightner AL, Fafaj A, Zolin SJ, Petro CC, Krpata DM, Prabhu AS, Holubar SD, Rosen MJ. Short-term outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. Hernia 2021; 25:1557-1564. [PMID: 34342743 DOI: 10.1007/s10029-021-02476-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/05/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. METHODS A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair. RESULTS Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair. CONCLUSION The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed.
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Affiliation(s)
- B C Perlmutter
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - H Alkhatib
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A Fafaj
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - S J Zolin
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
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Thomas JD, Fafaj A, Zolin SJ, Rosen MJ, Lipman JM, French JC, Prabhu AS, Krpata DM, Rosenblatt S, Horne CM, Khandelwal C, Petro CC. Registry-based Trainee Assessments: Leveraging a Quality Collaborative for Surgical Education. J Surg Res 2021; 268:136-144. [PMID: 34311295 DOI: 10.1016/j.jss.2021.06.017] [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] [Received: 12/14/2020] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We present our experience developing and embedding a registry-based module for resident feedback. METHODS At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020). RESULTS In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period. CONCLUSION By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.
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Affiliation(s)
- Jonah D Thomas
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Aldo Fafaj
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samuel J Zolin
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeremy M Lipman
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Judith C French
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S Prabhu
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Krpata
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Charlotte M Horne
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cathleen Khandelwal
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C Petro
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio.
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Tseng ES, Zolin SJ, Young BT, Claridge JA, Conrad-Schnetz KJ, Curfman ET, Wise NL, Lemaitre VC, Ho VP. Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study. J Trauma Acute Care Surg 2021; 91:212-218. [PMID: 33797489 PMCID: PMC8487055 DOI: 10.1097/ta.0000000000003174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Esther S. Tseng
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Brian T. Young
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jeffrey A. Claridge
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Eric T. Curfman
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicole L. Wise
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vetrica C. Lemaitre
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vanessa P. Ho
- Division of Trauma, Critical Care, Burns, and Emergency General Surgery, MetroHealth Medical Center, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
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Horne CM, Augenstein V, Malcher F, Yunis J, Huang LC, Zolin SJ, Fafaj A, Thomas JD, Krpata DM, Petro CC, Rosen MJ, Prabhu AS. Understanding the benefits of botulinum toxin A: retrospective analysis of the Abdominal Core Health Quality Collaborative. Br J Surg 2021; 108:112-114. [PMID: 33711107 DOI: 10.1093/bjs/znaa050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/14/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022]
Abstract
This was a retrospective analysis of a prospectively maintained database that objectively evaluated the benefit of preoperative chemical component separation with botulinum toxin A in complex hernia repairs.
Continued evaluation.
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Affiliation(s)
- C M Horne
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - V Augenstein
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - F Malcher
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J Yunis
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - L-C Huang
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - S J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J D Thomas
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - D M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
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15
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Fafaj A, Thomas J, Zolin SJ, Poli de Figueiredo SM, Tastaldi L, Liu PS, Petro CC, Krpata DM, Prabhu AS, Rosen MJ. Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score. J Am Coll Surg 2021; 232:948-953. [PMID: 33831538 DOI: 10.1016/j.jamcollsurg.2021.03.009] [Citation(s) in RCA: 1] [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: 02/05/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.
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Affiliation(s)
- Aldo Fafaj
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Jonah Thomas
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Samuel J Zolin
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Luciano Tastaldi
- Department of General Surgery, University of Texas Medical Branch, University Boulevard, Galveston, TX
| | - Peter S Liu
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Clayton C Petro
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David M Krpata
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ajita S Prabhu
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Michael J Rosen
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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Fafaj A, Tastaldi L, Alkhatib H, Zolin SJ, Rosenblatt S, Huang LC, Phillips S, Krpata DM, Prabhu AS, Petro CC, Rosen MJ. Management of ventral hernia defect during enterocutaneous fistula takedown: practice patterns and short-term outcomes from the Abdominal Core Health Quality Collaborative. Hernia 2021; 25:1013-1020. [PMID: 33389276 DOI: 10.1007/s10029-020-02347-8] [Citation(s) in RCA: 4] [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] [Received: 07/05/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). STUDY DESIGN Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. RESULTS 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. CONCLUSIONS Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.
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Affiliation(s)
- A Fafaj
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - L Tastaldi
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.,Department of General Surgery, University of Texas Medical Branch, 3100 University Boulevard, Galveston, TX, 77555, USA
| | - H Alkhatib
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - S J Zolin
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - S Rosenblatt
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - L-C Huang
- Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Dr., Nashville, TN, 37232, USA
| | - S Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Dr., Nashville, TN, 37232, USA
| | - D M Krpata
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
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17
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Zolin SJ, Bhangu JK, Young BT, Posillico SE, Ladhani HA, Claridge JA, Ho VP. Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts? Am Surg 2020; 87:1488-1495. [PMID: 33356466 DOI: 10.1177/0003134820972989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
BACKGROUND Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. METHODS Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. RESULTS Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). CONCLUSIONS Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.
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Affiliation(s)
- Samuel J Zolin
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA.,Department of General Surgery, Digestive Disease Institute, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jasmin K Bhangu
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA
| | - Brian T Young
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA
| | - Sarah E Posillico
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA
| | - Husayn A Ladhani
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA.,Department of Population and Quantitative Health Sciences, 12304Case Western Reserve University School of Medicine, Cleveland, OH, USA
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18
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Zolin SJ, Petro CC, Prabhu AS, Fafaj A, Thomas JD, Horne CM, Tastaldi L, Alkhatib H, Krpata DM, Rosenblatt S, Rosen MJ. Registry-Based Randomized Controlled Trials: A New Paradigm for Surgical Research. J Surg Res 2020; 255:428-435. [DOI: 10.1016/j.jss.2020.05.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 01/02/2023]
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19
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Naples R, Monteiro R, Thomas J, Zolin SJ, Shin JJ, Krishnamurthy VD, Berber E, Siperstein A. Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2,000 Consecutive Patients. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.144] [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: 10/23/2022]
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20
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Zolin SJ, Crawford K, Rudin AV, Harsono H, Krishnamurthy VD, Jin J, Berber E, Siperstein A, Shin JJ. Selective parathyroid venous sampling in reoperative parathyroid surgery: A key localization tool when noninvasive tests are unrevealing. Surgery 2020; 169:126-132. [PMID: 32651054 DOI: 10.1016/j.surg.2020.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/14/2020] [Accepted: 05/03/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. METHODS Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. RESULTS Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. CONCLUSION Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.
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Affiliation(s)
- Samuel J Zolin
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH.
| | - Kate Crawford
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Anatoliy V Rudin
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Hasly Harsono
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Judy Jin
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Allan Siperstein
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Joyce J Shin
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
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Fafaj A, Zolin SJ, Rossetti N, Thomas JD, Horne CM, Petro CC, Krpata DM, Prabhu AS, Rosenblatt S, Rosen MJ. Patient-reported opioid use after open abdominal wall reconstruction: How low can we go? Surgery 2020; 168:141-146. [DOI: 10.1016/j.surg.2020.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 01/15/2023]
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Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia 2020; 24:333-340. [PMID: 32152808 DOI: 10.1007/s10029-020-02150-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 12/05/2019] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure. METHODS Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center. RESULTS Recommendations regarding patient selection, optimization and technique for TAR are presented. CONCLUSIONS While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.
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Affiliation(s)
- S J Zolin
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA.
| | - A Fafaj
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
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Young BT, Zolin SJ, Beel KT, Harvey AR, Ho VP, Tseng ES, Claridge JA. Discussion on: Effects of ohio's opioid prescribing limit for the geriatric minimally injured trauma patient. Am J Surg 2020; 219:404-405. [PMID: 32199529 DOI: 10.1016/j.amjsurg.2020.02.003] [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: 11/24/2022]
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24
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Zolin SJ, Tastaldi L, Alkhatib H, Lampert EJ, Brown K, Fafaj A, Petro CC, Prabhu AS, Rosen MJ, Krpata DM. Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value? Hernia 2020; 24:759-770. [PMID: 31930440 DOI: 10.1007/s10029-019-02114-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE There is increasing emphasis on value in health care, defined as quality over cost required to deliver care. We analyzed outcomes and costs of repairing medium-sized ventral hernias to identify whether an open retromuscular or laparoscopic intraperitoneal onlay approach would provide superior value to the patient and healthcare system. METHODS A retrospective analysis of prospectively collected data from the Americas Hernia Society Quality Collaborative was performed for patients undergoing clean, elective repair of ventral hernias between 4 and 8 cm in width at our institution between 4/2013 and 12/2016 for whom at least 1-year follow-up was available. Recurrence rates, wound complications, length of stay, patient-reported outcomes, and perioperative costs were compared. RESULTS One hundred and eighty-six patients met criteria (105 open, 81 laparoscopic) with 93.5% having ≥ 2-year follow-up. Patients undergoing laparoscopic repair had higher BMI, lower ASA classification, slightly lower prevalence of recurrent hernias and less prior mesh utilization, and slightly smaller hernias. Length of stay was shorter in the laparoscopic group (median 1 vs. 3 days, p < 0.001), without increased readmissions. Recurrence rates, wound complications, and patient-reported outcomes were similar. Laparoscopic repair had higher up-front surgical costs, yet equivalent total perioperative costs. CONCLUSION Both laparoscopic and open approaches for elective repair of medium-sized ventral hernias offer similar clinical outcomes, patient-reported outcomes, and total perioperative costs. Laparoscopic repair appears to offer superior value based on a significantly reduced postoperative length of stay.
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Affiliation(s)
- S J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA.
| | - L Tastaldi
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - H Alkhatib
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - E J Lampert
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - K Brown
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - A Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
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Young BT, Zolin SJ, Ferre A, Ho VP, Harvey AR, Beel KT, Tseng ES, Conrad-Schnetz K, Claridge JA. Effects of Ohio's opioid prescribing limit for the geriatric minimally injured trauma patient. Am J Surg 2019; 219:400-403. [PMID: 31910990 DOI: 10.1016/j.amjsurg.2019.10.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/20/2019] [Accepted: 10/23/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Geriatric patients, age ≥65, frequently require no operation and only short observation after injury; yet many are prescribed opioids. We reviewed geriatric opioid prescriptions following a statewide outpatient prescribing limit. METHODS Discharge and 30-day pain prescriptions were collected for geriatric patients managed without operation and with stays less than two midnights from May and June of 2015 through 2018. Patients were compared pre- and post-limit and with a non-geriatric cohort aged 18-64. Fall risk was also assessed. RESULTS We included 218 geriatric patients, 57 post-limit. Patients received fewer discharge prescriptions and lower doses following the limit. However, this trend preceded the limit. Geriatric patients received fewer opioid prescriptions but higher doses than non-geriatric patients. Fall risk was not associated with reduced prescription frequency or doses. CONCLUSIONS Opioid prescribing has decreased for geriatric patients with minor injuries. However, surgeons have not reduced dosage based on age or fall risk.
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Affiliation(s)
- Brian T Young
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA.
| | - Samuel J Zolin
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA; Cleveland Clinic Foundation, Digestive Disease Institute, Department of General Surgery, Cleveland, OH, USA
| | - Alexandra Ferre
- Cleveland Clinic Foundation, Digestive Disease Institute, Department of General Surgery, Cleveland, OH, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA
| | - Alexis R Harvey
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA
| | - Kevin T Beel
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA
| | - Esther S Tseng
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA
| | - Kristen Conrad-Schnetz
- Cleveland Clinic Foundation, Digestive Disease Institute, Department of General Surgery, Cleveland, OH, USA
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, USA.
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Bhangu JK, Young BT, Posillico S, Ladhani HA, Zolin SJ, Claridge JA, Ho VP. Goals of Care Discussions for the Imminently Dying Trauma Patient. J Surg Res 2019; 246:269-273. [PMID: 31614324 DOI: 10.1016/j.jss.2019.07.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/19/2019] [Accepted: 07/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures. MATERIALS AND METHODS We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams. RESULTS A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001). CONCLUSIONS MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.
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Affiliation(s)
- Jasmin K Bhangu
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Brian T Young
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Sarah Posillico
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Husayn A Ladhani
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Samuel J Zolin
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
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Harvey AR, Young BT, Golob JF, Zolin SJ, Claridge JA, Ho VP. ACS-Verifed Trauma Hospitals Outperform Non-Verified Hospitals on Incentive-Driven Reduction of CAUTI. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1326] [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: 11/29/2022]
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Zolin SJ, Colvin J, Burneikis T, Jin J, Berber E, Krishnamurthy VD, Shin J, Siperstein A. Patient-Reported Outcomes Measurement Identifies Disease-Specific Symptom Improvement after Parathyroid and Thyroid Surgery. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.189] [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: 10/25/2022]
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Zolin SJ, Tastaldi L, Alkhatib H, Lampert EJ, Brown K, Cherla D, Petro C, Prabhu AS, Rosen M, Krpata DM. Assessing Relative Value of Ventral Hernia Repair Approaches: An AHSQC Analysis. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1007] [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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Zolin SJ, Burneikis T, Rudin AV, Shirley RB, Siperstein A. Analysis of a thyroid nodule care pathway: Opportunity to improve compliance and value of care. Surgery 2019; 166:691-697. [PMID: 31402128 DOI: 10.1016/j.surg.2019.05.054] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/09/2019] [Accepted: 05/19/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Care pathways facilitate standardized, evidence-based treatment to improve outcomes and value of care. Care pathways consist of multiple nodes representing decision points. Few studies investigate care pathway compliance. We demonstrate nodal care pathway analysis by reviewing compliance with our institutional multidisciplinary, evidence-based care pathways on the treatment of thyroid nodule to generate strategies to increase care pathway adherence and value of care. METHODS Patients undergoing workup and treatment of structural thyroid disease between January 2018 and June 2018 were included in a retrospective analysis of enterprise-wide compliance with the following 3 care pathway nodes: (1) laboratory testing: only patients with abnormal results from thyroid-stimulating hormone testing should have T3/T4 measured. (2) imaging: neck computed tomography, magnetic resonance imaging, and positron emission tomography ordered for the workup of nodules were reviewed to determine clinical appropriateness. (3) operative treatment: the first 200 thyroid resections conducted in 2018 were reviewed to determine whether the indication and extent of the operation complied with the care pathway. Medicare fee schedules were used for financial calculations. RESULTS Care pathway nonadherence occurred in 48% of the thyroid-stimulating hormone studies and 38% of the imaging studies obtained, with annual costs exceeding $120,000. Substantial care pathway nonadherence occurred in 3% of nodule-related operations. CONCLUSION Care pathway nodal analysis can identify areas of care pathway nonadherence. Nodal analysis should be considered for care pathway maintenance and generation of strategies of quality improvement.
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Zolin SJ, Ho VP, Young BT, Harvey AR, Beel KT, Tseng ES, Brown LR, Claridge JA. Opioid prescribing in minimally injured trauma patients: Effect of a state prescribing limit. Surgery 2019; 166:593-600. [PMID: 31326187 DOI: 10.1016/j.surg.2019.05.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 02/15/2019] [Revised: 03/27/2019] [Accepted: 05/01/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Opioid-prescribing practices for minimally injured trauma patients are unknown. We hypothesized that opioid-prescribing frequency and morphine-equivalent doses prescribed have decreased in recent years, specifically surrounding an acute prescribing limit implemented in August 2017 mandating opioid prescriptions not exceed 210 morphine-equivalent doses. METHODS A single-center retrospective study was performed in the month of May during the years 2015 to 2018 on minimally injured trauma patients in a level I trauma center. Minimally injured trauma patients included patients discharged within 2 midnights of trauma evaluation without surgical intervention. Primary outcomes were discharge opioid-prescribing frequency and dosing in morphine-equivalent doses. Secondary outcomes were occurrence and timing of postdischarge follow-up. RESULTS For 673 minimally injured trauma patients, opioid-prescribing frequency and morphine-equivalent doses prescribed decreased between 2015 and 2017 (49.3% to 31.5%, P = .006, mean 229 to 146 morphine-equivalent doses, P = .007). Decreases between 2017 and 2018 were not statistically significant. Acute prescribing limit compliance was 97% in 2018. After the acute prescribing limit was implemented, outpatient opioid prescribing did not increase and time to earliest follow-up did not decrease. CONCLUSION Opioid-prescribing frequency and morphine-equivalent doses prescribed to minimally injured trauma patients decreased dramatically between 2015 and 2018. These changes occurred primarily before the implementation of an acute prescribing limit; however, incremental improvement and high compliance since implementation are demonstrated. Patients did not have significantly earlier follow-up encounters for pain or additional opioid prescriptions. Prospective research on pain control for minimally injured trauma patients is needed.
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Affiliation(s)
- Samuel J Zolin
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Cleveland Clinic Foundation, Digestive Disease Institute, Department of General Surgery, Cleveland, OH.
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brian T Young
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Alexis R Harvey
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kevin T Beel
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Esther S Tseng
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Laura R Brown
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
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French JC, Zolin SJ, Lampert E, Aiello A, Bencsath KP, Ritter KA, Strong AT, Lipman JM, Valente MA, Prabhu AS. Gender and Letters of Recommendation: A Linguistic Comparison of the Impact of Gender on General Surgery Residency Applicants ✰. J Surg Educ 2019; 76:899-905. [PMID: 30598383 DOI: 10.1016/j.jsurg.2018.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/16/2018] [Accepted: 12/10/2018] [Indexed: 05/24/2023]
Abstract
OBJECTIVE We investigated letters of recommendation for general surgery residency applicants to determine if any gender-based disparities exist. DESIGN A dictionary of over 400 terms describing applicants and 24 unique categories into which these terms were classified was created. Word count and language comparisons were performed using linguistic analysis software to assess for differences in applicant characterization, letter length, and writing style between male and female applicants and letter writers. SETTING A large, Midwest, academic general surgery residency program. PARTICIPANTS Five hundred and fifty-nine letters of recommendation received during the 2015 and 2016 interview cycles were selected for analysis. RESULTS Average word count was approximately equal for male and female applicants (503 vs 508, respectively). Female writers wrote longer letters (mean word count 545.5 vs 497.1, p = 0.028). "Standout" terms were more likely to be used to describe female applicants. Otherwise no statistically significant differences in applicant characterization were discovered. CONCLUSIONS Letters of recommendation for general surgery are written using similar descriptive terms and lengths for male and female applicants. This suggests that there is no specific gender disadvantage with regard to letters of recommendation when applying for general surgery residency.
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Affiliation(s)
- Judith C French
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Samuel J Zolin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erika Lampert
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Alexandra Aiello
- Department of Quantitative Health Sciences, Cleveland Clinic Learner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kalman P Bencsath
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kaitlin A Ritter
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrew T Strong
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Jeremy M Lipman
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ajita S Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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