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Sarwahi V, Hasan S, Rao H, Visahan K, Grunfeld M, Dzaugis P, Wendolowski S, Vora R, Galina J, Lo Y, Moguilevitch M, Thornhill B, Amaral T, DiMauro JP. Does a dedicated "Scoliosis Team" and surgical standardization improve outcomes in adolescent idiopathic scoliosis surgery and is it reproducible? Spine Deform 2023; 11:1409-1418. [PMID: 37507585 DOI: 10.1007/s43390-023-00728-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions. METHODS A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ2 tests were used. RESULTS 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing. CONCLUSION Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes.
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Affiliation(s)
- Vishal Sarwahi
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA.
| | - Sayyida Hasan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Himanshu Rao
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Keshin Visahan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | | | - Peter Dzaugis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Stephen Wendolowski
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Rushabh Vora
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jesse Galina
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Yungtai Lo
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - Terry Amaral
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jon-Paul DiMauro
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
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Endo Y, Moazzam Z, Woldesenbet S, Lima HA, Alaimo L, Munir MM, Shaikh CF, Yang J, Azap L, Katayama E, Kitago M, Pawlik TM. Hospital Volume and Textbook Outcomes in Minimally Invasive Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2023; 27:956-964. [PMID: 36732402 DOI: 10.1007/s11605-023-05609-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/22/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hospital volume affects outcomes of patients who underwent resection for hepatocellular carcinoma (HCC). We sought to assess the impact of minimally invasive hepatectomy (MIH) volume on short- and long-term outcomes among patients with HCC. METHODS Patients who underwent MIH for HCC from 2010 to 2018 were identified from the National Cancer Database. Multivariable modeling with restricted cubic splines (RCS) was utilized to identify the MIH hospital volume threshold. Textbook outcome (TO) was defined as no conversion to open resection, negative margins after resection (R0), no extended length-of-stay, no readmission, and no 90-day mortality. RESULTS Among 3268 patients who underwent MIH for HCC, median age was 65.0 (IQR 59.0-72.0) and the majority was male (n = 2308, 70.6%). MIH hospital volume ranged from 1 to 87 cases, with a median of 13 (IQR 7-23). Overall, 2151 (60.9%) patients achieved TO after resection. While particularly high rates of achievement were found for no 90-day mortality (n = 3106, 95.0%), no readmission (n = 3153, 96.5%), and R0 resection (n = 3,017, 92.3%), other TO components including no conversion to open (n = 2778, 85.0%) and no prolonged LOS (n = 2584, 79.1%) were achieved less frequently. Patients treated at high-volume centers (≥50 MIH cases) were more likely to experience TO (high volume centers, n = 334, 68.7% vs. low volume centers, n = 1656, 59.5%, p < 0.001) and better long-term survival (5-year OS; high volume centers, 64.7% vs. low volume centers, 54.6%, p < 0.001). CONCLUSIONS MIH hospital volume was associated with a higher likelihood of achieving TO and improved long-term survival among patients undergoing resection of HCC.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Andersson R, Haglund C, Seppänen H, Ansari D. Pancreatic cancer - the past, the present, and the future. Scand J Gastroenterol 2022; 57:1169-1177. [PMID: 35477331 DOI: 10.1080/00365521.2022.2067786] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic cancer has been and still is associated with a very poor prognosis. This is due to a lack of major breakthroughs with respect to early diagnosis, prognostication, prediction, as well as novel, targeted therapies. The benefits of surgery and chemotherapy are evident, but the fact that only some 10% of all patients have early, localized disease highlights the unmet need for new early detection methods. An improved understanding of tumor biology and the development of molecular markers detectable both in the circulation and in cancer tissues may underlie the development of new tools for optimizing both diagnosis and treatment. MATERIAL AND METHODS Review of the literature. RESULTS AND CONCLUSION If we do not improve precision oncology for pancreatic ductal adenocarcinoma, the prognosis will still remain dismal and the" burden" on society will increase substantially.
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Affiliation(s)
- Roland Andersson
- Surgery, Department of Clinical Sciences Lund Lund University, Skåne University Hospital, Lund, Sweden
| | - Caj Haglund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Seppänen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Ansari
- Surgery, Department of Clinical Sciences Lund Lund University, Skåne University Hospital, Lund, Sweden
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Koo AB, Elsamadicy AA, Sarkozy M, Pathak N, David WB, Freedman IG, Reeves BC, Sciubba DM, Laurans M, Kolb L. Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 9:100099. [PMID: 35141663 PMCID: PMC8819911 DOI: 10.1016/j.xnsj.2022.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed. RESULTS A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost. CONCLUSION Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.
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Affiliation(s)
- Andrew B. Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Aladine A. Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Neil Pathak
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, United States
| | - Wyatt B. David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Isaac G. Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin C. Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Daniel M. Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.
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Attitudes Affecting Decision-making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons. J Surg Res 2021; 267:536-543. [PMID: 34256196 DOI: 10.1016/j.jss.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/14/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. METHODS We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. RESULTS The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. CONCLUSIONS Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Ejaz A, Pawlik TM. In-hospital Mortality Following Pancreatoduodenectomy: a Comprehensive Analysis. J Gastrointest Surg 2020; 24:1119-1126. [PMID: 31292889 DOI: 10.1007/s11605-019-04307-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed. METHODS Retrospective review of the National Inpatient Sample database (January 2004-December 2014) was conducted to identify patients undergoing PD. Factors associated with in-hospital mortality after PD were analyzed after adjusting for previously defined patient- and hospital-level risk factors. RESULTS A total of 9639 patients who underwent a PD at 2325 hospitals were identified. Median patient age was 57 years (IQR 66-73). Overall, mortality following PD was 3.2%. When patient- and hospital-level characteristics were analyzed in the same model, patient-level characteristic associated with increased odds of in-hospital mortality included increasing patient age (OR 1.05, 95% CI 1.03-1.06/per 5 years increase), male sex (OR 1.47, 95% CI 1.16-1.86), the presence of liver disease (OR 3.03, 95% CI 1.99-4.61), chronic kidney disease (OR 1.78, 95% CI 1.18-2.68), and congestive heart failure (OR 2.48, 95% CI 1.65-3.74). The only hospital characteristic associated with odds of mortality following PD included compliance with Leapfrog volume standards (OR 0.70, 95% CI 0.54-0.92). CONCLUSION Patient-level factors, such as advanced comorbidities, male sex, and increased age, contributed the most to increased risk of mortality after PD. Hospital volume was the only hospital-level factor contributing to risk of in-hospital mortality following PD.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Ahola R, Sand J, Laukkarinen J. Centralization of Pancreatic Surgery Improves Results: Review. Scand J Surg 2020; 109:4-10. [DOI: 10.1177/1457496919900411] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.
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Affiliation(s)
- R. Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Tampere University Hospital, Tampere, Finland
| | - J. Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Toward Standardized Management of Congenital Diaphragmatic Hernia: An Analysis of Practice Guidelines. J Surg Res 2019; 243:229-235. [DOI: 10.1016/j.jss.2019.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/10/2019] [Accepted: 05/01/2019] [Indexed: 11/20/2022]
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10
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Outcomes After Resection of Hepatocellular Carcinoma: Intersection of Travel Distance and Hospital Volume. J Gastrointest Surg 2019; 23:1425-1434. [PMID: 31069637 DOI: 10.1007/s11605-019-04233-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data on the impact of hospital volume and travel distance on patient outcomes after major abdominal surgery remain poorly defined. We sought to characterize the relationship of travel distance, hospital volume, and long-term outcomes of patients undergoing surgical resection of hepatocellular carcinoma (HCC). METHODS The 2004-2015 National Cancer Database was used to identify patients who underwent resection of HCC. Patients were stratified according to travel distance and hospital volume quartiles, and multivariable regression models were utilized to examine the impact of travel distance, hospital volume, and travel distance/hospital volume on overall survival (OS). RESULTS Among the 12,266 patients identified, procedures included wedge/segmental resections (N = 7354, 59.9%), hemi-hepatectomy (N = 4003, 32.6%), and extended hepatectomy (N = 909, 7.5%). Stratifying data into quartiles, travel distance to surgical care was ≤ 5.7 miles (mi), > 5.7-14.2 mi, > 14.2-44.4 mi, and ≥ 44.4 mi, while hospital volume quartiles determined on the hospital level were ≤ 1 case per year, 1.1-4, 4.1-12.5, and ≥ 12.5. On multivariable analysis, increased hospital volume was associated with decreased hazard of mortality (HR 0.69, 95% CI 0.45-0.82, p < 0.001). Travel distance was not significantly associated with hazard of mortality. Furthermore, only hospital volume was associated with mortality (HR 0.67, 95% CI 0.56-0.80, p < 0.001) after controlling for both travel distance and hospital volume. CONCLUSIONS Only hospital volume was associated with increased hazard of mortality. The benefits of undergoing resection for HCC at a high-volume hospital appear to outweigh the inconvenience of longer travel distances.
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Villano AM, Zeymo A, McDermott J, Barrak D, Unger KR, Shara NM, Chan KS, Al-Refaie WB. Regionalization of Retroperitoneal Sarcoma Surgery to High-Volume Hospitals: Missed Opportunities for Outcome Improvement. J Oncol Pract 2019; 15:e247-e261. [DOI: 10.1200/jop.18.00349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE: Surgery continues to be the dominant therapy for the management of retroperitoneal soft-tissue sarcoma (RPS). Many groups advocate performing these resections at high-volume hospitals (HVHs), given their complexity. We therefore sought to explore whether RPS surgery has indeed begun to regionalize to HVHs in the same manner as pancreatic cancer (PC) surgery during the last decade. METHODS: We identified 70,763 patients who underwent surgical resection for RPS or PC using the National Cancer Database (2004 to 2015). Patients were stratified by hospital surgical volume. We performed an adjusted time trend analysis to compare trends in performance of surgery at HVHs for RPS versus PC. Multivariable logistic analyses were then performed, controlling for covariables, to elucidate relationships between patient-, hospital-, and treatment-related variables that may contribute to these observed trends. RESULTS: Only 9.6% of patients underwent RPS surgery at HVHs. During this time period, the odds ratio of undergoing RPS compared with pancreatectomy at HVHs was 0.65 ( P < .05). Time trend analysis estimated that whereas both procedures are regionalizing, the rate of RPS regionalization grew at 30.5% of the rate of PC (1.017 v 1.056; P < .001) and remained consistent after using several hospital volume thresholds and hospital volume as a continuous variable. CONCLUSION: Results from this retrospective multi-institutional analysis uncovered a lag in the regionalization of surgery for RPS compared with PC surgery. These findings reinforce the call to regionalize surgery for RPS to HVHs in a manner that is similar to that of other procedures in complex cancer surgery.
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Affiliation(s)
- Anthony M. Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
| | - James McDermott
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Dany Barrak
- Medstar-Washington Hospital Center, Washington, DC
| | | | - Nawar M. Shara
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Kitty S. Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Waddah B. Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
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Boteon APCS, Boteon YL, Hodson J, Osborne H, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts JK, Sutcliffe RP. Multivariable analysis of predictors of unplanned hospital readmission after pancreaticoduodenectomy: development of a validated risk score. HPB (Oxford) 2019; 21:26-33. [PMID: 30049642 DOI: 10.1016/j.hpb.2018.06.1802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/20/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD. METHODS Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived. RESULTS 81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP>140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index >14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p < 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p < 0.001). CONCLUSION The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.
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Affiliation(s)
- Amanda P C S Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - James Hodson
- Medical Statistics, Institute of Translational Medicine, University Hospitals Birmingham, UK
| | - Helen Osborne
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John Isaac
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Ravi Marudanayagam
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Darius F Mirza
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John K Roberts
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Robert P Sutcliffe
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK.
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Prognostic impact of hospital volume on familial adenomatous polyposis: a nationwide multicenter study. Int J Colorectal Dis 2017; 32:1489-1498. [PMID: 28831607 DOI: 10.1007/s00384-017-2885-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Many studies have shown that hospital volume is significantly associated with short- and long-term outcomes in various diseases, including cancer. However, there have been no reports discussing the relationship between hospital volume and familial adenomatous polyposis (FAP). This study aimed to clarify whether hospital volume affects short- and long-term outcomes in FAP patients. METHODS We established a retrospectively collected database of FAP patients who underwent initial surgical treatment at 23 Japanese institutions during 2000-2012. Factors associated with short- and long-term outcomes were analyzed. RESULTS The study cohort included 303 FAP patients. These patients were classified into tertile categories according to hospital volume: low (n = 31), middle (n = 72), and high volume (n = 200). The proportion of only adenoma/stage 0 was comparable among tertile categories. The adoption of operative procedure significantly differed among tertile categories; specifically, high-volume institutions preferred handsewn ileal pouch-anal anastomosis without diverting ileostomy (P < 0.001 and < 0.001, respectively). Nevertheless, the frequency of complications with Clavien-Dindo classification grade ≥ 3 was not significantly different among tertile categories. Functional results were acceptable in every category. Wexner scores were significantly lower in high-volume compared to low-volume institutions (P = 0.02). Multivariate analyses showed that UICC stage and hospital volume were significantly associated with overall survival (P = 0.04 and 0.03, respectively). CONCLUSIONS Hospital volume was significantly associated with short- and long-term outcomes in FAP patients.
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Analysis of the Cost Effectiveness of Laparoscopic Pancreatoduodenectomy. J Gastrointest Surg 2017; 21:1404-1410. [PMID: 28567575 PMCID: PMC6032973 DOI: 10.1007/s11605-017-3466-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/23/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We sought to determine if laparoscopic pancreatoduodenectomy (LPD) is a cost-effective alternative to open pancreatoduodenectomy (OPD). METHODS Hospital cost data, discharge disposition, readmission rates, and readmission costs from periampullary cancer patient cohorts of LPD and OPD were compared. The surgical cohorts over a 40-month period were clinically similar, consisting of 52 and 50 patients in the LPD and OPD groups, respectively. RESULTS The total operating room costs were higher in the LPD group as compared to the OPD group (median US$12,290 vs US$11,299; P = 0.05) due to increased costs for laparoscopic equipment and regional nerve blocks (P ≤ 0.0001). Although hospital length of stay was shorter in the LPD group (median 7 vs 8 days; P = 0.025), the average hospital cost was not significantly decreased compared to the OPD group (median $28,496 vs $28,623). Surgery-related readmission rates and associated costs did not differ between groups. Compared to OPD patients, significantly more LPD patients were discharged directly home rather than to other healthcare facilities (88% vs 72%; P = 0.047). CONCLUSION For the index hospitalization, the cost of LPD is equivalent to OPD. Total episode-of-care costs may favor LPD via reduced post-hospital needs for skilled nursing and rehabilitation.
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Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, Jäger C, Friess H, Ceyhan GO. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2017; 161:939-950. [DOI: 10.1016/j.surg.2016.11.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 12/13/2022]
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van der Zee DC, Tytgat SHA, van Herwaarden MYA. Esophageal atresia and tracheo-esophageal fistula. Semin Pediatr Surg 2017; 26:67-71. [PMID: 28550873 DOI: 10.1053/j.sempedsurg.2017.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Management of esophageal atresia has merged from correction of the anomaly to the complete spectrum of management of esophageal atresia and all its sequelae. It is the purpose of this article to give an overview of all aspects involved in taking care of patients with esophageal atresia between January 2011 and June 2016, as well as the patients who were referred from other centers. Esophageal atresia is a complex anomaly that has many aspects that have to be dealt with and complications to be solved. By centralizing these patients in centers of expertise it is believed that the best care can be given.
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Affiliation(s)
- David C van der Zee
- Professor of Pediatric Surgery, Dept. Pediatric Surgery, University Medical Center Utrecht, The Netherlands.
| | - Stefaan H A Tytgat
- Pediatric Surgeon, Dept. Pediatric Surgery, University Medical Center Utrecht, The Netherlands
| | - Maud Y A van Herwaarden
- Pediatric Surgeon, Dept. Pediatric Surgery, University Medical Center Utrecht, The Netherlands
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Abstract
BACKGROUND A significant proportion of patients never receive curative-intent surgery for resectable gastric cancer (GC). The primary aims of this study were to identify disparities and targetable risk factors associated with failure to operate in the context of national trends in surgical rates for resectable GC. METHODS The National Cancer Database was used to identify patients with resectable GC (adenocarcinoma, clinical stage IA-IIIC, 2004-2013). Multivariate modeling was used to identify predictors of resection and to analyze the impact of surgery on overall survival (OS). RESULTS Of 46,970 patients with resectable GC, 18,085 (39%) did not receive an appropriate operation. Among unresected patients, 69% had no comorbidities. Failure to resect was associated with reduced median OS (44.4 versus 11.8 mo, hazard ratio [HR]: 2.09, P < 0.001). In the multivariate analysis, the most critical factors affecting OS were resection (HR: 2.09) and stage (reference IA; HR range: 1.16-3.50, stage IB-IIIC). Variables independently associated with no surgery included insurance other than private or Medicare (odds ratio [OR]: 1.60/1.54), nonacademic/nonresearch hospital (OR: 1.16), non-Asian race (OR: 1.72), male (OR: 1.19), older age (OR: 1.04), Charlson-Deyo score >1 (OR: 1.17), residing in areas with median income <$48,000 (OR: 1.23), small urban populations <20,000 (OR: 1.41), and stage (reference IA; OR range: 1.36-3.79, stage IB-IIIC, P < 0.001). CONCLUSIONS Over one-third of patients with resectable GC fail to receive surgery. Suitable insurance coverage and treatment facility are the most salient (and only modifiable) risk factors for omitting surgery. To mitigate national disparities in surgical care, policymakers should consider improving insurance coverage in underserved areas and regionalization of gastric cancer care.
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