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Jones D, Kumar S, Anstee C, Gingrich M, Simone A, Ahmadzai Z, Thavorn K, Seely A. Index hospital cost of adverse events following thoracic surgery: a systematic review of economic literature. BMJ Open 2023; 13:e069382. [PMID: 37770272 PMCID: PMC10546169 DOI: 10.1136/bmjopen-2022-069382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 07/26/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES Adverse events (AEs) following thoracic surgery place considerable strain on healthcare systems. A rigorous evaluation of the economic impact of thoracic surgical AEs remains lacking and is required to understand the value of money of formal quality improvement initiatives. Our objective was to conduct a systematic review of all available literature focused on specific cost of postoperative AEs following thoracic surgery. DESIGN Systematic review of the economic literature was performed, following recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES An economic search filter developed by the Canadian Agency for Drugs and Technologies in Health was applied, and MEDLINE, Embase and The Cochrane Library were searched from inception to January 2022. ELIGIBILITY CRITERIA We included English articles involving adult patients who underwent a thoracic surgical procedure with estimated costs of postoperative complications. Eligible study designs included comparative observational studies, randomised control trials, decision analytic or cost-prediction models, cost analyses, cost or burden of illness studies, economic evaluation studies and systematic reviews and/or meta-analyses of cost analyses and cost of illness studies. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened titles and abstracts in the first stage and full-text articles of included studies in the second stage. Disagreements during abstract and full-text screening stages were resolved via discussion until a consensus was reached. Studies were appraised for methodological quality using the Critical Appraisal Skills Program checklist. RESULTS 3349 studies were identified: 20 met inclusion criteria. Most were conducted in the USA (12/20), evaluating AE impact on hospital expenditures (18/20). 68 procedure-specific AE mean costs were characterised (USD$). The most commonly described were anastomotic leak (mean:range) (USD$49 278:$6 176-$133 002) and pneumonia ($12 258:$2608-$34 591) following esophagectomy, and prolonged air leak ($2556:$571-$3573), respiratory failure ($19 062:$11 841-$37 812), empyema ($30 189:$23 784-$36 595), pneumonia ($15 362:$2542-$28 183), recurrent laryngeal nerve injury ($16 420:$4224-$28 616) and arrhythmia ($6835:$5833-$8659) following lobectomy. CONCLUSIONS Hospital costs associated with AEs following thoracic surgery are substantial and varied. Quantifying costs of AEs enable future economic evaluation studies, which could help prioritising value-directed quality improvement to optimally improve outcomes and reduce costs.
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Affiliation(s)
- Daniel Jones
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Srishti Kumar
- Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Caitlin Anstee
- Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Molly Gingrich
- Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexander Simone
- Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrew Seely
- Department of Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
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Grantham JP, Hii A, Shenfine J. Combined and intraoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:1485-1500. [PMID: 37555117 PMCID: PMC10405120 DOI: 10.4240/wjgs.v15.i7.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions. AIM To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes. METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness. RESULTS Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness. CONCLUSION Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- Department of General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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Sakowitz S, Mabeza RM, Bakhtiyar SS, Verma A, Ebrahimian S, Vadlakonda A, Revels S, Benharash P. Acute clinical and financial outcomes of esophagectomy at safety-net hospitals in the United States. PLoS One 2023; 18:e0285502. [PMID: 37224136 DOI: 10.1371/journal.pone.0285502] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND While safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy. METHODS All adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010-2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days. RESULTS Of an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03-1.50), intraoperative complications (AOR 1.45, 95% CI 1.20-1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35-1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64-2.10), costs (+10,400, 95% CI 6,900-14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00-1.23). CONCLUSIONS Care at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Sha'shonda Revels
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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Lussiez A, Eton R, Anderson M, Valbuena V, Campbell D, Englesbe M, Howard R. Heterogeneity in Surgical Quality Improvement in Michigan. Ann Surg 2023; 277:612-618. [PMID: 35129495 DOI: 10.1097/sla.0000000000005282] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. SUMMARY BACKGROUND DATA Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. METHODS We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. RESULTS There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). CONCLUSIONS Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Ryan Eton
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Maia Anderson
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Valeria Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
| | - Darrell Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Jacobs MA, Kim J, Tetley JC, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery. J Am Coll Surg 2023; 236:352-364. [PMID: 36648264 DOI: 10.1097/xcs.0000000000000468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical outcome/cost analyses typically focus on single outcomes and do not include encounters beyond the index hospitalization. STUDY DESIGN This cohort study used NSQIP (2013-2019) data with electronic health record and cost data risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status, and operative stress assessing cumulative costs of failure to achieve textbook outcomes defined as absence of 30-day Clavien-Dindo level III and IV complications, emergency department visits/observation stays (EDOS), and readmissions across insurance types (private, Medicare, Medicaid, uninsured). Return costs were defined as costs of all 30-day emergency department visits/observation stays and readmissions. RESULTS Cases were performed on patients (private 1,506; Medicare 1,218; Medicaid 1,420; uninsured 2,178) with a mean age 52.3 years (SD 14.7) and 47.5% male. Medicaid and uninsured patients had higher odds of presenting with preoperative acute serious conditions (adjusted odds ratios 1.89 and 1.81, respectively) and undergoing urgent/emergent surgeries (adjusted odds ratios 2.23 and 3.02, respectively) vs private. Medicaid and uninsured patients had lower odds of textbook outcomes (adjusted odds ratios 0.53 and 0.78, respectively) and higher odds of emergency department visits/observation stays and readmissions vs private. Not achieving textbook outcomes was associated with a greater than 95.1% increase in cumulative costs. Medicaid patients had a relative increase of 23.1% in cumulative costs vs private, which was 18.2% after adjusting for urgent/emergent cases. Return costs were 37.5% and 65.8% higher for Medicaid and uninsured patients, respectively, vs private. CONCUSIONS Higher costs for Medicaid patients were partially driven by increased presentation acuity (increased rates/odds of preoperative acute serious conditions and urgent/emergent surgeries) and higher rates of multiple emergency department visits/observation stays and readmission occurrences. Decreasing surgical costs/improving outcomes should focus on reducing urgent/emergent surgeries and improving postoperative care coordination, especially for Medicaid and uninsured populations.
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Affiliation(s)
- Michael A Jacobs
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jasmine C Tetley
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine (Brimhall), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Virginia Mika
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Chen-Pin Wang
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians (Manuel), University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX (Damien)
| | - Paula K Shireman
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX (Shireman)
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The effect of preoperative patient-reported anxiety on morbidity and mortality outcomes in patients undergoing major general surgery. Sci Rep 2022; 12:6312. [PMID: 35428818 PMCID: PMC9012824 DOI: 10.1038/s41598-022-10302-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 01/03/2023] Open
Abstract
Excessive levels of anxiety may negatively influence treatment outcomes and likely increase patient suffering. We designed a prospective observational study to assess whether preoperative patient-reported anxiety affects major general surgery outcomes. We prospectively administered the State-Trait Anxiety Inventory (STAI) to measure preoperative anxiety in patients awaiting major general surgical procedures. Patients were grouped by STAI scores according to established cutoffs: no anxiety (STAI < 40) and anxiety (STAI ≥ 40). Four hundred patients completed the questionnaires and underwent surgery, with an average interval from questionnaire completion to surgery of 4 days. Applying a state anxiety (STAI-S) score ≥ 40 as a reference point, the prevalence of patient-reported anxiety was 60.5% (241 of 400). The mean STAI-S score for these patients was 50.48 ± 7.77. The mean age of the entire cohort was 58.5 ± 14.12 years. The majority of participants were male (53.8%). The distribution of sex by anxiety status showed that 53.5% of women and 46.5% of men had anxiety (p = 0.003). In the entire cohort, postoperative complications occurred in 23.9% and 28.6% of the no anxiety and anxiety groups, respectively. The difference was nonsignificant. In a subgroup of patients who underwent high-risk complex procedures (N = 221), however, postoperative complications occurred in 31.4% and 45.2% of the no anxiety and anxiety groups, respectively. This difference was significant at p = 0.004. Of the patients who were anxious, 3.3% (8 of 241) died during hospitalization following surgery, compared with 4.4% of the patients (7 of 159) who were not anxious (p = 0.577). In the multivariable analysis adjusted for covariates and based on the results of subgroup analysis, preoperative anxiety assessed by the STAIS score was associated with morbidity (OR 2.12, CI 1.14–3.96; p = 0.018) but not mortality. The majority of enrolled patients in this study were classified as having high- to very high-level preoperative clinical anxiety, and we found a significant quantitative effect of patient-reported anxiety on morbidity but not mortality after surgery.
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Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer. Langenbecks Arch Surg 2022; 407:2001-2009. [PMID: 35288787 PMCID: PMC9399199 DOI: 10.1007/s00423-022-02486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/25/2022] [Indexed: 11/26/2022]
Abstract
Purpose The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes. Methods Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models. Results Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03–1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06–2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19–2.31, p = 0.003). Conclusion Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.
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Brajcich BC, Yuce TK, Merkow RP, Bilimoria KY, McGee MF, Zhan T, Odell DD. Association of preoperative smoking with complications following major gastrointestinal surgery. Am J Surg 2022; 223:312-317. [PMID: 34119328 PMCID: PMC8648850 DOI: 10.1016/j.amjsurg.2021.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery. METHODS Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes. RESULTS A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]). CONCLUSIONS Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA.
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Tiannan Zhan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
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Kassahun WT, Babel J, Mehdorn M. Assessing differences in surgical outcomes following emergency abdominal exploration for complications of elective surgery and high-risk primary emergencies. Sci Rep 2022; 12:1349. [PMID: 35079087 PMCID: PMC8789789 DOI: 10.1038/s41598-022-05326-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/06/2022] [Indexed: 11/09/2022] Open
Abstract
Irrespective of its etiology, emergency surgical abdominal exploration (EAE) is considered a high-risk procedure with mortality rates exceeding 20%. The aim of this study was to evaluate differences in outcomes in patients who required EAE due to complications of complex elective abdominal procedures and those who required EAE due to high-risk primary abdominal emergencies. Patients undergoing EAE for acute surgical complications of complex abdominal elective surgical procedures (N = 293; Elective group) and patients undergoing EAE for high-risk primary abdominal emergencies (N = 776; Emergency group) from 2012 to 2019 at our institution were retrospectively assessed for morbidity and mortality. Postoperative complications occurred in 196 patients (66.94%) in the elective group and 585 patients (75.4%) in the emergency group. The relatively low complication burden in the elective group was also evidenced by a significantly lower comprehensive complication index score (54.00 ± 37.36 vs. 59.25 ± 37.08, p = 0.040). The in-hospital mortality rates were 31% (91 of 293) and 38% (295 of 776) in the elective and emergency groups, respectively. This difference between the two groups was statistically significant (p = 0.035). In multivariate analysis, age, peripheral artery disease, pneumonia, thromboembolic events, ICU stay, ventilator dependence, acute kidney failure and liver failure were independent predictors of mortality. Our data show that patients undergoing EAE due to acute complications of major elective surgery tolerate the procedure relatively well compared with patients undergoing EAE due to primary high-risk abdominal emergencies.
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Affiliation(s)
- Woubet Tefera Kassahun
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany.
| | - Jonas Babel
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
| | - Matthias Mehdorn
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
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Chen Z, Huang K, Wei R, Liu C, Fang Y, Wu B, Xu Z, Ding X, Tang H. Transcervical inflatable mediastinoscopic esophagectomy versus thoracoscopic esophagectomy for local early‐ and intermediate‐stage esophageal squamous cell carcinoma: A propensity score‐matched analysis. J Surg Oncol 2022; 125:839-846. [PMID: 35066884 PMCID: PMC9304140 DOI: 10.1002/jso.26798] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 01/31/2023]
Abstract
Background and objective Transcervical inflatable mediastinoscopic esophagectomy (TIME) is a novel method of minimally invasive esophagectomy (MIE) for esophageal cancer. However, whether TIME is effective and feasible as conventional MIE remains unclear. This study aimed to evaluate the efficacy of TIME by comparing it with thoracoscopic esophagectomy (TE). Methods Surgical outcomes and relapse‐free survival (RFS) rates of patients with local early‐ or intermediate‐stage thoracic esophageal squamous cell carcinoma that underwent TIME or TE from January 2017 to December 2019 were analyzed in this retrospective study. Propensity score matching was used to control the confounding factors. Results The mean operation time in TIME was shorter than that in TE (p < 0.05). Patients in the TIME group achieved postoperative ambulation earlier than those in the TE group (p < 0.05). The rate of pulmonary complications was lower in TIME than in TE (p < 0.05). The number of lymph nodes harvested during surgery and the RFS rates of two groups did not have significant differences. Conclusion TIME may be a feasible and safe method to treat local early‐ and intermediate‐stage thoracic esophageal squamous cell carcinoma effectively and it could be a supplementary surgical method of TE for patients with poor pulmonary function or cannot undergo TE.
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Affiliation(s)
- Zihao Chen
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Kenan Huang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Rongqiang Wei
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Chengdong Liu
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Yunhao Fang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Bin Wu
- Department of Thoracic Surgery Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Zhifei Xu
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Xinyu Ding
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Hua Tang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
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Geraedts ACM, Alberga AJ, Koelemay MJW, Verhagen HJM, Vahl AC, Balm R. Short-term outcomes of open surgical abdominal aortic aneurysm repair from the Dutch Surgical Aneurysm Audit. BJS Open 2021; 5:6369775. [PMID: 34518868 PMCID: PMC8438252 DOI: 10.1093/bjsopen/zrab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR. Methods Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented. Results A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications. Conclusion The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.
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Affiliation(s)
- A C M Geraedts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - A J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands
| | - M J W Koelemay
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - A C Vahl
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - R Balm
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Shirakawa Y, Noma K, Kunitomo T, Hashimoto M, Maeda N, Tanabe S, Sakurama K, Fujiwara T. Initial introduction of robot-assisted, minimally invasive esophagectomy using the microanatomy-based concept in the upper mediastinum. Surg Endosc 2020; 35:6568-6576. [PMID: 33170337 PMCID: PMC7654354 DOI: 10.1007/s00464-020-08154-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
Background We have recently standardized upper mediastinal lymph node dissection (UMLND) using a microanatomy-based concept in thoracoscopic esophagectomy in the prone position (TEPP), and introduced robot-assisted minimally invasive esophagectomy (RAMIE) using the same concept as in TEPP while aiming at solo surgery. The purpose of this study was to investigate the outcomes of RAMIE using the microanatomy-based concept in the initial introduction phase. Methods We have performed more than 500 TEPP procedures as minimally invasive esophagectomy (MIE). After performing about 400 cases of MIE, we established a microanatomy-based standardization of UMLND. In October 2018, we introduced RAMIE, and have performed 75 procedures in 20 months. Two groups were analyzed: a group after microanatomy-based standardization in TEPP (100 cases after completing 400 cases of TEPP) and a RAMIE group (75 cases). Finally, 51 paired cases were matched using a propensity score. Furthermore, the change in postoperative short-term outcome for RAMIE in the initial introduction phase was analyzed. Results Although there were no significant differences between the two groups in the number of upper mediastinal lymph nodes dissected, there was a significant decrease (P = 0.036) in intraoperative blood loss volume with RAMIE, representing a definite benefit for patients. The thoracoscopic operative time for RAMIE decreased by almost 100 min following less than 50 cases of experience, reaching the same level as that for recent TEPP, but with only one-tenth the operator experience. There were no significant differences in the total postoperative morbidity rate including the recurrent laryngeal nerve palsy rate. Conclusion RAMIE has been introduced safely and smoothly using the microanatomy-based concept established in TEPP.
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Affiliation(s)
- Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. .,Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoyoshi Kunitomo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masashi Hashimoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazufumi Sakurama
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Wanderer JP, Lasko TA, Coco JR, Fowler LC, McEvoy MD, Feng X, Shotwell MS, Li G, Gelfand BJ, Novak LL, Owens DA, Fabbri DV. Visualization of aggregate perioperative data improves anesthesia case planning: A randomized, cross-over trial. J Clin Anesth 2020; 68:110114. [PMID: 33142248 DOI: 10.1016/j.jclinane.2020.110114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE A challenge in reducing unwanted care variation is effectively managing the wide variety of performed surgical procedures. While an organization may perform thousands of types of cases, privacy and logistical constraints prevent review of previous cases to learn about prior practices. To bridge this gap, we developed a system for extracting key data from anesthesia records. Our objective was to determine whether usage of the system would improve case planning performance for anesthesia residents. DESIGN Randomized, cross-over trial. SETTING Vanderbilt University Medical Center. MEASUREMENTS We developed a web-based, data visualization tool for reviewing de-identified anesthesia records. First year anesthesia residents were recruited and performed simulated case planning tasks (e.g., selecting an anesthetic type) across six case scenarios using a randomized, cross-over design after a baseline assessment. An algorithm scored case planning performance based on care components selected by residents occurring frequently among prior anesthetics, which was scored on a 0-4 point scale. Linear mixed effects regression quantified the tool effect on the average performance score, adjusting for potential confounders. MAIN RESULTS We analyzed 516 survey questionnaires from 19 residents. The mean performance score was 2.55 ± SD 0.32. Utilization of the tool was associated with an average score improvement of 0.120 points (95% CI 0.060 to 0.179; p < 0.001). Additionally, a 0.055 point improvement due to the "learning effect" was observed from each assessment to the next (95% CI 0.034 to 0.077; p < 0.001). Assessment score was also significantly associated with specific case scenarios (p < 0.001). CONCLUSIONS This study demonstrated the feasibility of developing of a clinical data visualization system that aggregated key anesthetic information and found that the usage of tools modestly improved residents' performance in simulated case planning.
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Affiliation(s)
- Jonathan P Wanderer
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States.
| | - Thomas A Lasko
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Joseph R Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Leslie C Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, United States
| | - Matthew S Shotwell
- Department of Biostatistics, Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Brian J Gelfand
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Laurie L Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - David A Owens
- Owen Graduate School of Management, Vanderbilt University, United States
| | - Daniel V Fabbri
- Department of Biomedical Informatics, Department of Computer Science, Vanderbilt University Medical Center, United States
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Kulshrestha S, Bunn C, Gonzalez R, Afshar M, Luchette FA, Baker MS. Unhealthy alcohol and drug use is associated with an increased length of stay and hospital cost in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Surgery 2020; 169:636-643. [PMID: 32951904 DOI: 10.1016/j.surg.2020.07.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few studies evaluate the impact of unhealthy alcohol and drug use on the risk and severity of postoperative outcomes after upper gastrointestinal and pancreatic oncologic resections. METHODS The National Inpatient Sample was queried to identify patients undergoing total gastrectomy, esophagectomy, total pancreatectomy, and pancreaticoduodenectomy between 2012 and 2015. Unhealthy alcohol and drug use was assessed by the International Classification of Diseases, Ninth Revision, and National Inpatient Sample coder designation. Multivariable regression was used to identify associations between alcohol and drug use and postoperative complication, duration of stay, hospital cost, and mortality. RESULTS In the study, 59,490 patients met inclusion criteria; 2,060 (3.5%) had unhealthy alcohol use; 1,265 (2.1%) had unhealthy drug use. Postoperative complication rates were higher in patients with alcohol and drug use than in abstainers (67.5% vs 62.8% vs 57.2%; P < .01). On multivariable regression, alcohol use was independently associated with increased risk of a nonwithdrawal complication (odds ratio 1.33 [1.05, 1.68]), and alcohol and drug use were independently associated with increased length of stay (1.54 [0.12, 2.96]) and 2.22 [0.90, 3.55] days) and cost ($5,471 [$60, $10,881] and $4,022 [$402, $7,643]), but not mortality. CONCLUSION Unhealthy substance use is associated with increased rates of postoperative complications, prolonged length of stay, and costs in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Screening and abstinence interventions should be incorporated into the preoperative care pathways for these patients.
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Affiliation(s)
- Sujay Kulshrestha
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL
| | - Corinne Bunn
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL
| | - Richard Gonzalez
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL
| | - Majid Afshar
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL; Center for Health Outcomes and Informatics Research, Health Sciences Division, Loyola University Chicago, Maywood, IL; Department of Health Informatics and Data Science, Loyola University Chicago, Chicago, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Hines, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Hines, IL.
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Yip HC, Shirakawa Y, Cheng CY, Huang CL, Chiu PWY. Recent advances in minimally invasive esophagectomy for squamous esophageal cancer. Ann N Y Acad Sci 2020; 1482:113-120. [PMID: 32783237 DOI: 10.1111/nyas.14461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 12/29/2022]
Abstract
Over the past decade there has been tremendous development in the clinical application of minimally invasive esophagectomy (MIE) for the treatment of squamous esophageal carcinoma. The major challenges in the performance of MIE include limitations in visualization and manipulation within the confined, rigid thoracic cavity; the need for adequate patient positioning and anesthetic techniques to accommodate the surgical exposure; and changes in the surgical steps for achieving radical nodal dissection, especially for the superior mediastinum. The surgical procedure for MIE is more and more standardized, and there is an increasing practice of MIE worldwide. Randomized trials and meta-analyses have confirmed the advantages of MIE over open esophagectomy, including a significantly lower rate of complications and shorter hospital stays. The recent application of robotics technologies for MIE has further enhanced the quality and safety of the surgical dissection, while intraoperative nerve monitoring has contributed to a lower rate of recurrent laryngeal nerve palsy. With the application of new technologies, we expect further improvement in surgical outcomes for MIE in the treatment of squamous esophageal cancer.
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Affiliation(s)
- Hon Chi Yip
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ching-Yuan Cheng
- Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chang-Lun Huang
- Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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Perioperative Risk Factors Associated With Acute Kidney Injury in Patients After Brain Tumor Resection. J Neurosurg Anesthesiol 2020; 34:51-56. [PMID: 32658102 DOI: 10.1097/ana.0000000000000716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication after surgery. The aim of this study is to identify risk factors for postoperative AKI in patients undergoing brain tumor surgery. METHODS This single-center, retrospective, matched case-control study included patients undergoing elective brain tumor surgery between January 2016 and December 2018 at Beijing Tiantan Hospital, Capital Medical University, China. Patients developing postoperative AKI were compared with controls without AKI matched by age, sex, and date of surgery in a ratio of 1:3. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. RESULTS A total of 9933 patients were identified for review, of which 115 (1.16%) developed AKI; 345 matched patients were included in the control group. AKI occurred most commonly within the first 24 hours (41/97, 42.3%) and 48 hours (33/94, 35.1%) after surgery. Preoperative administration of mannitol (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.04-2.60; P= 0.034), American Society of Anesthesiologists physical status III or higher (OR, 5.50; 95% CI, 2.23-13.59; P<0.001), preoperative blood glucose (OR, 2.53; 95% CI, 1.23-5.22; P=0.012), craniopharyngioma (OR, 8.96; 95% CI, 3.55-22.63; P<0.001), nonsteroidal anti-inflammatory drug administration (OR, 3.74; 95% CI, 1.66-8.42; P<0.001), and intraoperative hypotension (OR, 2.13; 95% CI, 1.21-3.75; P=0.009) were independent risk factors for postoperative AKI. CONCLUSION Multiple factors, including preoperative administration of mannitol, are independently associated with the development of postoperative AKI in patients undergoing brain tumor surgery.
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Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial. J Physiother 2020; 66:180-187. [PMID: 32680742 DOI: 10.1016/j.jphys.2020.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/09/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
QUESTION Is preoperative physiotherapy cost-effective in reducing postoperative pulmonary complications (PPC) and improving quality-adjusted life years (QALYs) after major abdominal surgery? DESIGN Cost-effectiveness analysis from the hospitals' perspective within a multicentre randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS Four hundred and forty-one adults awaiting elective upper abdominal surgery attending pre-anaesthetic clinics at three public hospitals in Australia and New Zealand. INTERVENTIONS The experimental group received an information booklet and a 30-minute face-to-face session, involving respiratory education and breathing exercise training, with a physiotherapist. The control group received the information booklet only. OUTCOME MEASURES The probability of cost-effectiveness and incremental net benefits was estimated using bootstrapped incremental PPC and QALY cost-effectiveness ratios plotted on cost-effectiveness planes and associated probability curves through a range of willingness-to-pay amounts. Cost-effectiveness modelling utilised 21-day postoperative hospital cost audit data and QALYs estimated from Short Form-Six Domain health utilities and mortality to 12 months. RESULTS Preoperative physiotherapy had 95% probability of being cost-effective with an incremental net benefit to participating hospitals of A$4,958 (95% CI 10 to 9,197) for each PPC prevented, given that the hospitals were willing to pay $45,000 to provide the service. Cost-utility for QALY gains was less certain. Sensitivity analyses strengthened cost-effectiveness findings. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. CONCLUSIONS Preoperative physiotherapy aimed at preventing PPCs was highly likely to be cost-effective from the hospitals' perspective. For each PPC prevented, preoperative physiotherapy is likely to cost the hospitals less than the costs estimated to treat a PPC after surgery. Potential QALY gains require confirmation. TRIAL REGISTRATION ACTRN12613000664741.
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Yalamanchi P, Parent A, Thorne M. Optimization of Delivery of Pediatric Otolaryngology Surgical Antibiotic Prophylaxis. Otolaryngol Head Neck Surg 2020; 163:275-279. [PMID: 32571162 DOI: 10.1177/0194599820933191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES There is limited evidence regarding use of routine perioperative antibiotics for pediatric otolaryngologic procedures. The objectives of this quality improvement study were (1) to characterize the otolaryngology case mix for which antibiotics were delivered and (2) determine the percentage of surgical encounters with appropriate timing of antibiotic administration. METHODS Pediatric otolaryngology procedures meeting criteria from 2015 to 2019 were evaluated as a component of an institution-wide pediatric surgical antibiotic prophylaxis study using A3 problem solving to identify and roll out interventions for appropriate antibiotic administration. Descriptive statistical analysis of the interrupted time-series data was used to describe the otolaryngology case mix for which antibiotics were delivered. The primary outcome measure was percentage of surgical encounters with appropriate timing of antibiotic administration in minutes relative to incision. RESULTS In total, 1520 pediatric otolaryngology procedures with perioperative antibiotic delivery were performed from July 2015 to September 2019. While surgical site infection number (n = 2/year) was stable, administration of timely prophylactic antibiotics significantly improved: 27.5% of cases per month at baseline and 86.9% at the conclusion of the rollout of the sequential interventions (P < .001). DISCUSSION Given the exceedingly low infection rate of clean otolaryngology surgery, there is limited evidence in favor of perioperative antibiotics for the majority of procedures. Prophylactic antibiotics were most commonly used in otologic surgery involving cochlear implantation or in the setting of draining ears or cholesteatoma and in clean-contaminated head and neck surgery cases. IMPLICATIONS FOR PRACTICE Iterative continuous performance improvement can optimize evidence-based delivery of preoperative prophylactic antibiotics. Additional interventions to ensure antimicrobial stewardship in pediatric otolaryngology are indicated.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley Parent
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Marc Thorne
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Impact of Reduced Preincision Antibiotic Infusion Time on Surgical Site Infection Rates: A Retrospective Cohort Study. Ann Surg 2020; 271:774-780. [PMID: 30169395 DOI: 10.1097/sla.0000000000003030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Our objective was to determine the impact of total preincision infusion time on surgical site infections (SSIs) and establish an optimal time threshold for subsequent prospective study. BACKGROUND SSIs remain a major cause of morbidity. Although regulated, the total time of infusion of preincision antibiotics varies widely. Impact of infusion time on SSI risk is poorly understood. METHODS All consecutive patients (n = 46,791) undergoing inpatient surgical intervention were retrospectively enrolled (2014-2015) and monitored for 1 year. Primary outcomes: the presence of SSI infection as predicted by reduced preoperative antibiotic infusion time. SECONDARY OUTCOMES preintervention compliance, the impact of a quality improvement algorithm to optimize infusion time compliance. Multivariate logistic regression of the retrospective cohort demonstrated predictors of infection. Receiver-operating characteristic analysis demonstrated the timing threshold predictive of infection. Cost impact of avoidable infections was analyzed. RESULTS Only 36.1% of patients received preincision infusion of vancomycin in compliance with national and institutional standards (60-120 min). Cephalosporin infusion times were 53 times more likely to be compliant [odds ratio (OR) 53.33, P < 0.001]. Vancomycin infusion times that were not compliant with national standards (less than standard 60-120 min) did not predict infection. However, significantly noncompliant, reduced preincision infusion time, significantly predicted SSI (<24.6 min infusion, AUC = 0.762). Vancomycin infusion, initiated too close to surgical incision, predicted increased SSI (OR = 4.281, P < 0.001). Implementation of an algorithm to improve infusion time, but not powered to demonstrate infection /reduction, improved vancomycin infusion start time (257% improvement, P < 0.001) and eliminated high-risk infusions (sub-24.6 min). CONCLUSIONS Initially, vancomycin infusion rarely met national guidelines; however, minimal compliance breach was not associated with SSI implications. The retrospective data here suggest a critical infusion time for infection reduction (24.6 min before incision). Prospective implementation of an algorithm led to 100% compliance. These data suggest that vancomycin administration timing should be studied prospectively.
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20
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Kaufman EJ, Hatchimonji JS, Ma LW, Passman J, Holena DN. Complications and Failure to Rescue After Abdominal Surgery for Trauma in Obese Patients. J Surg Res 2020; 251:211-219. [PMID: 32171135 DOI: 10.1016/j.jss.2020.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/06/2020] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication. METHODS We analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR. RESULTS Of 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0). CONCLUSIONS Obesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.
| | - Justin S Hatchimonji
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Passman
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Shirakawa Y, Noma K, Maeda N, Tanabe S, Sakurama K, Fujiwara T. Microanatomy-based standardization of left upper mediastinal lymph node dissection in thoracoscopic esophagectomy in the prone position. Surg Endosc 2020; 35:349-357. [PMID: 32043161 DOI: 10.1007/s00464-020-07407-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although thoracoscopic esophagectomy in the prone position (TEPP) has become a standard procedure for esophageal cancer surgery, upper mediastinal lymph node dissection (UMLND) on the left side remains an issue. We have recently developed a new standardized approach to left UMLND in TEPP based on the microanatomy of the membranes and layers with the aim of achieving quick and safe surgery. The purpose of this study was to establish and evaluate our new standardized procedure in left UMLND. PATIENTS AND METHODS Patients were divided into 2 groups: a pre-standardization group (n = 100) and a post-standardization group (n = 100). Eventually, 83 paired cases were matched using propensity score matching. In our new standardized procedure, left UMLND was performed while focusing on the visceral sheath, vascular sheath, and the fusion layer between them using a magnified view. RESULTS The thoracoscopic operative time was significantly shorter (P < 0.001) in the post-standardization group [n = 83; 209.0 (176.0-235.0) min] than in the pre-standardization group [n = 83; 235.5 (202.8-264.5) min]. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss between the two groups. There was a tendency for the total postoperative morbidity to decrease in the post-standardization group. Furthermore, the left recurrent laryngeal nerve palsy rate was significantly lower in the post-standardization group (18.1% to 8.7%, P = 0.015). CONCLUSION Microanatomy-based standardization contributes to safe and efficient left UMLND.
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Affiliation(s)
- Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan.
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazufumi Sakurama
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
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Abstract
BACKGROUND There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes. OBJECTIVE This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes. DESIGN This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome. SETTING January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative. PATIENTS A total of 2947 patients undergoing elective colectomy were selected. MAIN OUTCOME MEASURES The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments. RESULTS The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04). LIMITATIONS This study focused on outcomes and did not consider processes of care as drivers of value. CONCLUSIONS In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMÍA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atención quirúrgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprensión de las interacciones entre el rendimiento clínico, utilización eficiente de los servicios y costos de los episodios quirúrgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomía sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago múltiple y resultados clínicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuación de valor (proporción de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el análisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clínico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 días, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomía electiva.Pagos por episodio de 30 días, ajustados al riesgo y estandarizados por precio.La tasa media de complicación ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pagó $3807 (17%) más que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) más altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centró en los resultados y no se consideraron a los procesos de atención, como impulsores de valor.En la colectomía electiva, los hospitales de alto valor logran pagos de episodios más bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, más allá que la reducción de complicaciones. Objetivos valiosos para optimizar el valor de la colectomía electiva, pueden incluir mejoras en los protocolos de recuperación, así como otras intervenciones que aumenten la eficiencia en todas las fases de la atención. Vea el resumen del video en http://links.lww.com/DCR/B56.
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Identification of the clinically most relevant postoperative complications after gastrectomy: a population-based cohort study. Gastric Cancer 2020; 23:339-348. [PMID: 31482476 PMCID: PMC7031165 DOI: 10.1007/s10120-019-00997-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was to identify the clinically most relevant complications after gastrectomy, using the population-attributable fraction (PAF). METHODS Between 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account. RESULTS In total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% [95% CI 19.3-39.1] and 21.6% [95% CI 10.5-32.7], respectively) and prolonged hospitalization (PAF 12.9% [95% CI 9.7-16.0] and 14.7% [95% CI 11.0-18.8], respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% [95% CI 20.5-29.7]) and reoperations (PAF 30.3% [95% CI 24.3-36.3]). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% [95% CI 3.2-10.9]). Other complications only had a small effect on these outcomes. CONCLUSION Surgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.
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The impact of surgical site infections on hospital contribution margin-a European prospective observational cohort study. Infect Control Hosp Epidemiol 2019; 40:1374-1379. [PMID: 31619300 DOI: 10.1017/ice.2019.273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital. OBJECTIVE We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs). METHODS This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted. RESULTS Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) -2045 (IQR, -12,800 to 4,848) versus CHF 895 (IQR, -2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin. CONCLUSIONS Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.
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King C, Rourke KF. Urethral Stricture is Frequently a Morbid Condition: Incidence and Factors Associated With Complications Related to Urethral Stricture. Urology 2019; 132:189-194. [DOI: 10.1016/j.urology.2019.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 01/08/2023]
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Canizares MF, Feldman L, Miller PE, Waters PM, Bae DS. Pollicization of the Index Finger in the United States: Early Readmission and Complications. J Hand Surg Am 2019; 44:795.e1-795.e8. [PMID: 30446294 DOI: 10.1016/j.jhsa.2018.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 08/10/2018] [Accepted: 10/09/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Pollicization is a well-accepted treatment for thumb hypoplasia, yet little is known about the reasons why patients return early in the postoperative period and complications that occur after surgery. The purpose of this investigation was to describe 30-day returns, readmission, and complication rates after pollicization in the United States. METHODS A total of 459 pollicization procedures performed in 408 patients at 38 U.S. pediatric hospitals from 2003 to 2014 were identified using the Pediatric Health Information System database. A stepwise search strategy identified returns and readmissions within 30 days after pollicization to quantify complications and/or additional procedures. Risk factors for readmission and complications were compared across groups using uni- and multivariable general linear modeling. RESULTS There were 61 patients who returned to the hospital (emergency department, ambulatory surgery, or inpatient hospitalization) within 30 days of their pollicization. Of those, 39 patients returned for suture removal, cast changes, or other expected aspects of postoperative care. The remaining 22 patients had a total of 26 complications, accounting for a 4.8% complication rate. The majority had vascular complications and wound problems. Single complications ranging from wound infection to hemorrhage were found in 20 cases. Overall, 35 of the 61 returns were readmitted to the hospital for treatment of complications or additional procedures. There was no effect of age group, diagnosis, geographical region, or physician subspecialty on the likelihood of complication or readmission. CONCLUSIONS Sixty-one patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%), most commonly vascular in nature. These baseline data are informative because they identify opportunities for future preventative measures and quality improvement. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Maria F Canizares
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA
| | - Lanna Feldman
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA
| | - Patricia E Miller
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA
| | - Peter M Waters
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA
| | - Donald S Bae
- Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA.
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Lee MJ, Sayers AE, Drake TM, Marriott PJ, Anderson ID, Bach SP, Bradburn M, Hind D, Verjee A, Fearnhead NS. National prospective cohort study of the burden of acute small bowel obstruction. BJS Open 2019; 3:354-366. [PMID: 31183452 PMCID: PMC6551410 DOI: 10.1002/bjs5.50136] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022] Open
Abstract
Background Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK. Methods This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected. Results Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication. Conclusion Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes.
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Affiliation(s)
- M J Lee
- Department of General Surgery Northern General Hospital Sheffield UK.,South Yorkshire Surgical Research Group Sheffield UK
| | - A E Sayers
- South Yorkshire Surgical Research Group Sheffield UK.,Department of General Surgery Doncaster Royal Infirmary Doncaster UK
| | - T M Drake
- South Yorkshire Surgical Research Group Sheffield UK.,Department of Clinical Surgery University of Edinburgh Edinburgh UK
| | - P J Marriott
- Department of General Surgery Warwick Hospital Warwick UK.,Department of General Surgery Salford Royal Infirmary Salford UK
| | - I D Anderson
- West Midlands Research Collaborative, Academic Department of Surgery Queen Elizabeth Hospital Birmingham UK
| | - S P Bach
- Academic Department of Surgery Queen Elizabeth Hospital Birmingham UK
| | - M Bradburn
- Clinical Trials and Research Unit University of Sheffield Sheffield UK
| | - D Hind
- Clinical Trials and Research Unit University of Sheffield Sheffield UK
| | - A Verjee
- Patient Representative, Association of Coloproctology of Great Britain and Ireland Patient Liaison Group London UK
| | - N S Fearnhead
- Department of Surgery Addenbrooke's Hospital Cambridge UK
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Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections. J Am Coll Surg 2019; 228:98-106. [DOI: 10.1016/j.jamcollsurg.2018.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 12/13/2022]
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Geller AD, Zheng H, Gaissert H, Mathisen D, Muniappan A, Wright C, Lanuti M. Relative Incremental Cost of Postoperative Complications of Esophagectomy. Semin Thorac Cardiovasc Surg 2019; 31:290-299. [DOI: 10.1053/j.semtcvs.2018.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/26/2018] [Indexed: 11/11/2022]
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31
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Goense L, Meziani J, Ruurda JP, van Hillegersberg R. Impact of postoperative complications on outcomes after oesophagectomy for cancer. Br J Surg 2018; 106:111-119. [PMID: 30370938 DOI: 10.1002/bjs.11000] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/13/2018] [Accepted: 08/21/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND To allocate healthcare resources optimally, complication-related quality initiatives should target complications that have the greatest overall impact on outcomes after surgery. The aim of this study was to identify the most clinically relevant complications after oesophagectomy for cancer in a nationwide cohort study. METHODS Consecutive patients who underwent oesophagectomy for cancer between January 2011 and December 2016 were identified from the Dutch Upper Gastrointestinal Cancer Audit. The adjusted population attributable fraction (PAF) was used to estimate the impact of specific postoperative complications on the clinical outcomes postoperative mortality, reoperation, prolonged hospital stay and readmission to hospital in the study population. The PAF represents the percentage reduction in the frequency of a given outcome (such as death) that would occur in a theoretical scenario where a specific complication (for example anastomotic leakage) was able to be prevented completely in the study population. RESULTS Some 4096 patients were analysed. Pulmonary complications and anastomotic leakage had the greatest overall impact on postoperative mortality (risk-adjusted PAF 44·1 and 30·4 per cent respectively), prolonged hospital stay (risk-adjusted PAF 31·4 and 30·9 per cent) and readmission to hospital (risk-adjusted PAF 7·3 and 14·7 per cent). Anastomotic leakage had the greatest impact on reoperation (risk-adjusted PAF 47·1 per cent). In contrast, the impact of other complications on these outcomes was relatively small. CONCLUSION Reducing the incidence of pulmonary complications and anastomotic leakage may have the greatest clinical impact on outcomes after oesophagectomy.
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Affiliation(s)
- L Goense
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J Meziani
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
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Pinto BB, Walder B. Heart rate as a predictor and a therapeutic target of cardiac ischemic complications after non-cardiac surgery. A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Thein HH, Jembere N, Thavorn K, Chan KKW, Coyte PC, de Oliveira C, Hur C, Earle CC. Estimates and predictors of health care costs of esophageal adenocarcinoma: a population-based cohort study. BMC Cancer 2018; 18:694. [PMID: 29945563 PMCID: PMC6020438 DOI: 10.1186/s12885-018-4620-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Esophageal adenocarcinoma (EAC) incidence is increasing rapidly. Esophageal cancer has the second lowest 5-year survival rate of people diagnosed with cancer in Canada. Given the poor survival and the potential for further increases in incidence, phase-specific cost estimates constitute an important input for economic evaluation of prevention, screening, and treatment interventions. The study aims to estimate phase-specific net direct medical costs of care attributable to EAC, costs stratified by cancer stage and treatment, and predictors of total net costs of care for EAC. METHODS A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data from 2003 to 2011. The mean net costs of EAC care per 30 patient-days (2016 CAD) were estimated from the payer perspective using phase of care approach and generalized estimating equations. Predictors of net cost by phase of care were based on a generalized estimating equations model with a logarithmic link and gamma distribution adjusting for sociodemographic and clinical factors. RESULTS The mean net costs of EAC care per 30 patient-days were $1016 (95% CI, $955-$1078) in the initial phase, $669 (95% CI, $594-$743) in the continuing care phase, and $8678 (95% CI, $8217-$9139) in the terminal phase. Overall, stage IV at diagnosis and surgery plus radiotherapy for EAC incurred the highest cost, particularly in the terminal phase. Strong predictors of higher net costs were receipt of chemotherapy plus radiotherapy, surgery plus chemotherapy, radiotherapy alone, surgery alone, and chemotherapy alone in the initial and continuing care phases, stage III-IV disease and patients diagnosed with EAC later in a calendar year (2007-2011) in the initial and terminal phases, comorbidity in the continuing care phase, and older age at diagnosis (70-74 years), and geographic region in the terminal phase. CONCLUSIONS Costs of care vary by phase of care, stage at diagnosis, and type of treatment for EAC. These cost estimates provide information to guide future resource allocation decisions, and clinical and policy interventions to reduce the burden of EAC.
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Affiliation(s)
- Hla-Hla Thein
- 0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada ,0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - Nathaniel Jembere
- 0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Kednapa Thavorn
- 0000 0000 9606 5108grid.412687.eOttawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON Canada ,0000 0001 2182 2255grid.28046.38School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON Canada ,0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences (ICES uOttawa), Ottawa, ON Canada
| | - Kelvin K. W. Chan
- 0000 0001 2157 2938grid.17063.33Department of Medicine, University of Toronto, Toronto, ON Canada ,0000 0000 9743 1587grid.413104.3Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada
| | - Peter C. Coyte
- 0000 0001 2157 2938grid.17063.33Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada
| | - Claire de Oliveira
- 0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCentre for Addiction and Mental Health, Toronto, ON Canada
| | - Chin Hur
- 0000 0004 0386 9924grid.32224.35Gastroenterology Division, Massachusetts General Hospital, Boston, MA USA ,000000041936754Xgrid.38142.3cHarvard Medical School, Boston, MA USA
| | - Craig C. Earle
- 0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Department of Medicine, University of Toronto, Toronto, ON Canada ,0000 0000 9743 1587grid.413104.3Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada ,0000 0001 1457 1558grid.484022.8Canadian Partnership Against Cancer, Toronto, ON Canada
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Akyar S, Armenia SJ, Ratnani P, Merchant AM. The Impact of Frailty on Postoperative Cardiopulmonary Complications in the Emergency General Surgery Population. Surg J (N Y) 2018; 4:e66-e77. [PMID: 29796424 PMCID: PMC5966303 DOI: 10.1055/s-0038-1655756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/10/2018] [Indexed: 01/12/2023] Open
Abstract
Background
The burden of frail patients undergoing emergency general surgery (EGS) is increasing rapidly and this population is particularly susceptible to postoperative cardiopulmonary complications and mortality. We aimed to determine the association between frailty, as defined by the previously described modified frailty index (mFI), and postoperative respiratory complications (unplanned reintubation, pneumonia, and prolonged ventilation), cardiac complications (myocardial infarction and cardiac arrest), and mortality. We also sought to identify the most significant determinants of frailty in the highest risk patients based on the specific variables comprising the mFI.
Methods
We performed a retrospective observational analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Files from 2005 to 2015 identified 132,765 inpatients who underwent EGS. mFI scores were calculated for each patient. The effect of increasing frailty on unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality was evaluated using bivariate analysis. Multivariable logistic regression was used to compare mFI with additional predictor variables including race, gender, physical status as defined by the American Society of Anesthesiologists, disseminated cancer, renal failure, smoking status, sepsis, wound presence/classification, dyspnea, and previous ventilator dependence.
Results
Unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality were significantly associated with frailty, and the odds of each postoperative complication increased with increasing mFI score. Of the frailest patients (mFI ≥3) that experienced cardiopulmonary complications or mortality, the variables of the mFI that contributed most to frailty were hypertension requiring medication and functional status before surgery.
Conclusions
A higher mFI score is associated with increased odds of postoperative cardiopulmonary complications and mortality in the EGS population. Specific variables of the mFI can also provide valuable information for assessing odds in the frailest patients undergoing EGS.
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Affiliation(s)
- Serra Akyar
- Department of Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, New Jersey
| | - Sarah J Armenia
- Department of Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, New Jersey
| | - Parita Ratnani
- Department of Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, New Jersey
| | - Aziz M Merchant
- Department of Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, New Jersey
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Abstract
PURPOSE OF REVIEW Among critically ill patients, acute kidney injury (AKI) is still a common and serious complication with a tremendous impact on short-term and long-term outcomes. The objective of this review is to discuss strategies for renal protection and prevention of AKI in ICU patients. RECENT FINDINGS It is fundamental to identify patients at risk for AKI as soon as possible and as accurately as possible. In order to achieve these goals, translational approaches implementing new biomarkers have shown promising results. Focusing on the role of potential preventive strategies, hemodynamic stabilization is the most important intervention with proven efficacy. Recent published data undermined any hope that high-dose statin therapy in statin-naïve patients could exert renoprotective effects. However, preliminary data revealed the renoprotective activity of dexmedetomidine when used as a sedative agent. Moreover, several studies demonstrated the protective effects of remote ischemic preconditioning in various organs including the kidneys. The use of balanced crystalloid instead of hyperchloremic solutions also contributes to the reduction of AKI in critically ill patients. SUMMARY To prevent AKI, it is crucial to identify patients at risk as early as possible. Establishing hemodynamic stability and an adequate intravascular volume state to ensure a sufficient perfusion pressure is the only effective therapeutic intervention. It is self-evident that nephrotoxic agents should be avoided whenever it is possible.
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McGillion MH, Duceppe E, Allan K, Marcucci M, Yang S, Johnson AP, Ross-Howe S, Peter E, Scott T, Ouellette C, Henry S, Le Manach Y, Paré G, Downey B, Carroll SL, Mills J, Turner A, Clyne W, Dvirnik N, Mierdel S, Poole L, Nelson M, Harvey V, Good A, Pettit S, Sanchez K, Harsha P, Mohajer D, Ponnambalam S, Bhavnani S, Lamy A, Whitlock R, Devereaux PJ. Postoperative Remote Automated Monitoring: Need for and State of the Science. Can J Cardiol 2018; 34:850-862. [PMID: 29960614 DOI: 10.1016/j.cjca.2018.04.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 01/12/2023] Open
Abstract
Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.
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Affiliation(s)
- Michael H McGillion
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Emmanuelle Duceppe
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Katherine Allan
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Maura Marcucci
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Stephen Yang
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | - Ted Scott
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Carley Ouellette
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shaunattonie Henry
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yannick Le Manach
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Guillaume Paré
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Bernice Downey
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Sandra L Carroll
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Joseph Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Wendy Clyne
- Hope for the Community, Community Interest Company, Coventry, United Kingdom
| | - Nazari Dvirnik
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Laurie Poole
- Ontario Telemedicine Network, Toronto, Ontario, Canada
| | | | - Valerie Harvey
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amber Good
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Karla Sanchez
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Prathiba Harsha
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Sanjeev Bhavnani
- Scripps Clinic and Research Institute, La Jolla, California, USA
| | - Andre Lamy
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - P J Devereaux
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Economic Cost Analysis Related to Complications in General and Digestive Surgery. Cir Esp 2018; 96:292-299. [PMID: 29690996 DOI: 10.1016/j.ciresp.2018.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 01/09/2018] [Accepted: 02/13/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The aim was to assess the impact on economic costs and length of stay (LOS) of postoperative complications. METHODS 5,822 records from BMDS (2014-2015) are included. A descriptive, univariate and multivariate study evaluated the correlation between complications, Clavien-Dindo grade and vacation periods with LOS and economic costs, based on a full-cost model, aggregated by DRG. RESULTS AND CONCLUSIONS Mean cost per stay was €676.71, and €4,309.02 per episode. Complications appeared in 639 patients (11%). Admission to ICU was required in 203 patients, re-operation in 134 and re-admission in 243, while 66 patients died (1.1%). Complications caused significantly longer LOS (20.08 vs 5.48 days) and higher economic cost (€11,670.31 vs €3,354.12); infectious complications were the most frequent and respiratory the most expensive (€20,428.53), together with ICU admission (€20,242.66). Clavien-Dindo grade correlated with greater LOS and costs (except gradev). During vacation periods, complications and LOS are increased, but costs of these complications and LOS did not differ significantly from complications detected in non-vacation periods.
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Geller AD, Zheng H, Mathisen DJ, Wright CD, Lanuti M. Relative incremental costs of complications of lobectomy for stage I non–small cell lung cancer. J Thorac Cardiovasc Surg 2018; 155:1804-1811. [DOI: 10.1016/j.jtcvs.2017.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/19/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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Pirson M, Dehanne F, Van den Bulcke J, Leclercq P, Martins D, De Wever A. Evaluation of cost and length of stay, linked to complications associated with major surgical procedures. Acta Clin Belg 2018. [PMID: 28629305 DOI: 10.1080/17843286.2017.1338850] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A lot of studies have demonstrated the possibility of reducing the number of post-operative complications in the domain of major surgical procedures with the use of medical preventive techniques. However, complications following surgical procedures are unfortunately frequent and are a major problem, not only because of the impact for the patient, but also because of economic consequences that they provoke. The aim of the present study is to evaluate the extra length of stay and the extra cost, born by the hospital and the social security, linked to complications, incurring after major surgical procedures. MATERIAL AND METHODS Study based on the data from 13 Belgian hospitals for the year 2012. Complications were extracted through medical discharge summaries. The cost born by the social security was assessed on the basis of the billing data, hospital cost are taken from cost accounting studies. RESULTS The rate of complication for all the hospitals is 6.6%. About 30.3% of inpatient stays having a major or extreme severity of index had a complication during the stay, 1.8% of stays with a minor or moderate severity of index had a complication. The extra length of stay is 19.38 days when the stay has had a complication (p < 0.001). The additional mean cost borne from the hospital perspective is €21 353.07 and €8 026.65 for the social security. This additional mean cost varies greatly from one hospital to another. DISCUSSION/CONCLUSION The present study has shown that the actual financing do not cover real hospital costs in the field of major surgical procedures having caused complications. Results should encourage Belgian authorities to propose and finance preventive measures in order to reduce these complications, which represent major economic impacts, not only for authorities but also for hospitals.
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Affiliation(s)
- M. Pirson
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - F. Dehanne
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
- CHU UCL Namur, Belgique
| | - J. Van den Bulcke
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - P. Leclercq
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - D. Martins
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - A. De Wever
- Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
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Selby LV, Gennarelli RL, Schnorr GC, Solomon SB, Schattner MA, Elkin EB, Bach PB, Strong VE. Association of Hospital Costs With Complications Following Total Gastrectomy for Gastric Adenocarcinoma. JAMA Surg 2017; 152:953-958. [PMID: 28658485 DOI: 10.1001/jamasurg.2017.1718] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described. Objective To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma. Design, Setting, and Participants This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute-designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016. Main Outcomes and Measures Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications. Results In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]). Conclusions and Relevance Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.
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Affiliation(s)
- Luke V Selby
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Renee L Gennarelli
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Geoffrey C Schnorr
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark A Schattner
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elena B Elkin
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B Bach
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
Acute kidney injury (AKI) is a common complication in surgical patients and is associated with increases in mortality, an increased risk for chronic kidney disease and hemodialysis after discharge, and increased cost. Better understanding of the risk factors that contribute to perioperative AKI has led to improved AKI prediction and will eventually lead to improved prevention of AKI, mitigation of injury when AKI occurs, and enhanced recovery in patients who sustain AKI. The development of advanced clinical prediction scores for AKI, new imaging techniques, and novel biomarkers for early detection of AKI provides new tools toward these ends.
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Burkhart RA, Javed AA, Ronnekleiv-Kelly S, Wright MJ, Poruk KE, Eckhauser F, Makary MA, Cameron JL, Wolfgang CL, He J, Weiss MJ. The use of negative pressure wound therapy to prevent post-operative surgical site infections following pancreaticoduodenectomy. HPB (Oxford) 2017; 19:825-831. [PMID: 28602643 DOI: 10.1016/j.hpb.2017.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/22/2017] [Accepted: 05/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rates of superficial surgical site infection (SSI) following pancreaticoduodenectomy remain high. Following resection for cancer, complications such as SSI impact adjuvant therapy delivery and portend worse survival. An incisional negative pressure dressing (iVAC) has been demonstrated to reduce SSI in other high-risk cohorts. METHODS Following a comprehensive effort to identify patients at high risk for SSI, the practice patterns at a single academic center shifted and iVAC use increased. SSI rates were tracked in a prospectively maintained database and are reported. RESULTS 394 patients underwent pancreaticoduodenectomy over 21 months. 120 patients (30.5%) had an iVAC applied. The overall rate of SSI was 19.8%. On multivariate analysis, increased risk for SSI was associated with neoadjuvant therapy, preoperative biliary interventions and prior abdominal surgery. iVAC use decreased the rate of SSI (OR 0.45, p = 0.015). In the highest-risk patients, SSI rate declined from 50% in patients without an iVAC to 19.1% with iVAC use (p = 0.015). CONCLUSION The use of an iVAC following pancreaticoduodenectomy is associated with decreased SSI rates. This is particularly true for patients at highest risk as defined by a previously established risk scoring system in patients undergoing open pancreaticoduodenectomy.
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Affiliation(s)
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Michael J Wright
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Katherine E Poruk
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Vetterlein MW, Seisen T, Speed J, Friedlander DF, Meyer CP, Kibel AS, Menon M, Fisch M, Chun FKH, Sun M, Eswara JR, Trinh QD. 30-Day Adverse Events Following Cystectomy for Bladder Cancer Versus Benign Bladder Conditions. UROLOGY PRACTICE 2017. [DOI: 10.1016/j.urpr.2016.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Malte W. Vetterlein
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Seisen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Urology, Pitié-Salpêtrière Hospital, Pierre and Marie Curie University, Paris, France
| | - Jacqueline Speed
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David F. Friedlander
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian P. Meyer
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S. Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mani Menon
- VUI Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix K.-H. Chun
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxine Sun
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jairam R. Eswara
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Garbens A, Goldenberg M, Wallis CJD, Tricco A, Grantcharov TP. The cost of intraoperative adverse events in abdominal and pelvic surgery: A systematic review. Am J Surg 2017; 215:163-170. [PMID: 28709625 DOI: 10.1016/j.amjsurg.2017.06.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/30/2017] [Accepted: 06/13/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The assessment of intra-operative adverse events (iAEs) is a vastly under researched area with the potential to provide new methods on how to improve patient outcomes and hospital costs. Our objective was to determine the relationship between iAEs and total hospital costs in abdominal and pelvic surgery. DATA SOURCES We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Embase, MEDLINE and EBM Reviews online databases were searched to identify all studies that reported iAE rates and total hospital costs. We then analyzed the costing approach used in each article using the Drummond tool and evaluated articles quality using the GRADE method. CONCLUSIONS In total, 1709 unique references were identified through our literature search. After review, 23 were included. All studies that reported iAE rates and cost as the primary outcome found that iAEs significantly increased total hospital costs. We identified a relationship between iAEs and increased hospital costs. Future studies need to be performed to further evaluate the relationship between iAEs and cost as current studies are of low quality.
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Affiliation(s)
- A Garbens
- Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - M Goldenberg
- Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - C J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - A Tricco
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, ON, Canada.
| | - T P Grantcharov
- Division of General Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada.
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Li YP, Wang SN, Lee KT. Robotic versus conventional laparoscopic cholecystectomy: A comparative study of medical resource utilization and clinical outcomes. Kaohsiung J Med Sci 2017; 33:201-206. [PMID: 28359408 DOI: 10.1016/j.kjms.2017.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 01/18/2017] [Accepted: 01/18/2017] [Indexed: 01/27/2023] Open
Abstract
Conventional laparoscopic cholecystectomy (CLC) is currently the standard of surgical procedure for gallstone disease. Robotic cholecystectomy (RC) has revolutionized the field of minimally invasive surgery; it is safe and ergonomic, but expensive. The aim of this study is to compare the medical resource utilization and clinical outcomes between the two procedures. This study was conducted retrospectively by assessing data of the clinical outcomes and medical resource of 78 patients receiving RC and 367 patients receiving CLC. We reviewed the data of operation times, length of hospital stay, hospital charges, outpatient department visits, outpatient department service charges, and postoperative complications, which were retrieved from the health information system (HIS) database in this hospital. Patients in both groups had similar demographic and clinical features. The RC group had longer length of hospital stay (p=0.056), significantly longer operation time (p=0.035), and much more hospital charges (p=0.001). The RC group, however, experienced less postoperative complication rates (average 3.8% vs. 20.4%, p=0.001). Conversion rate was 1.9% in the CLC group versus 0% in the RC group (p=0.611). Most complications were mild, and following the Clavien-Dindo classification, there were two cases (2.5%) Grade I for the RC group; 50 cases (13.6%) Grade I and 14 cases (3.81%) Grade II for the CLC group (p<0.001 and 0.001, respectively). Procedure-related complications of Grade IIIa status were encountered in nine patients (2.45%) in the CLC group and none in the RC group (p=0.002).The RC group consumed more medical resources in the index hospitalization; however, they experienced significantly less postoperative complications.
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Affiliation(s)
- Yu-Pei Li
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shen-Nien Wang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - King-Teh Lee
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Gu LH, Li FH, Xia Q, Fang H, Zhang SJ, Han LZ. Diagnosis and outcomes of collateral arterial formation after irreversible early hepatic artery thrombosis in pediatric liver recipients. Hepatobiliary Pancreat Dis Int 2017; 16:39-44. [PMID: 28119257 DOI: 10.1016/s1499-3872(16)60165-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Early hepatic artery thrombosis (eHAT) has been recognized as an important cause of graft loss and mortality. However, the incidence, etiology and outcome are not clear, especially for children. The present study was to investigate the formation of collateral artery flow after irreversible eHAT and its impact on patient's prognosis. METHODS We analyzed eHAT after liver transplantation in children from October 2006 to April 2015 in our center, illustrated the formation of collateral hepatic artery flow after irreversible eHAT and explored the diagnosis, complications, treatment and prognosis. The basic and follow-up ultrasonographic images were also compared. RESULTS Of the 330 pediatric liver recipients, 22 (6.67%) developed eHAT within 1 month. Revascularization attempts including surgical thrombectomy, interventional radiology and conservational treatment (thrombolysis) were successful in 5 patients. Among the 17 patients who had irreversible eHAT, follow-up ultrasonography revealed that collateral artery flow was developed as early as 2 weeks after eHAT. Liver abscess and bile duct complication occurred secondary to eHAT in variable time. CONCLUSIONS Collateral arterial formation is a compensatory adaptation to eHAT to supply blood to liver grafts. However, the severe bile duct damage secondary to eHAT is irreversible and retransplantation is unavoidable.
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Affiliation(s)
- Li-Hong Gu
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China.
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Goense L, van Dijk WA, Govaert JA, van Rossum PSN, Ruurda JP, van Hillegersberg R. Hospital costs of complications after esophagectomy for cancer. Eur J Surg Oncol 2016; 43:696-702. [PMID: 28012715 DOI: 10.1016/j.ejso.2016.11.013] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to estimate the economic burden of postoperative complications after esophagectomy for cancer, in order to optimally allocate resources for quality improvement initiatives in the future. METHODS A retrospective analysis of prospectively collected clinical and financial outcomes after esophageal cancer surgery in a tertiary referral center in the Netherlands was performed. Data was extracted from consecutive patients registered in the Dutch Upper GI Cancer Audit between 2011 and 2014 (n = 201). Costs were measured up to 90-days after hospital discharge and based on Time-Driven Activity-Based Costing. The additional costs were estimated using multiple linear regression models. RESULTS The average total cost for one patient after esophagectomy was €37,581 (±31,372). The estimated costs of an esophagectomy without complications were €23,476 (±6496). Mean costs after minor (47%) and severe complications (29%) were €31,529 (±23,359) and €59,167 (±42,615) (p < 0.001), respectively. The 5% most expensive patients were responsible for 20.3% of the total hospital costs assessed in this study. Patient characteristics associated with additional costs in multivariable analysis included, age >70 (+€2,922, p = 0.036), female gender (+€4,357, p = 0.005), COPD (+€5,415, p = 0.002), and a history of thromboembolic events (+€6,213, p = 0.028). Complications associated with a significant increase in costs in multivariable analysis included anastomotic leakage (+€4,123, p = 0.008), cardiac complications (+€5,711, p = 0.003), chyle leakage (+€6,188, p < 0.001) and postoperative bleeding (+€31,567, p < 0.001). CONCLUSIONS Complications and severity of complications after esophageal surgery are associated with a substantial increase in costs. Although not all postoperative complications can be prevented, implementation of preventive measures to reduce complications could result in a considerable cost reduction and quality improvement.
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Affiliation(s)
- L Goense
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | | | - J A Govaert
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - P S N van Rossum
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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Lobdell KW, Fann JI, Sanchez JA. “What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery. Ann Thorac Surg 2016; 102:1052-8. [DOI: 10.1016/j.athoracsur.2016.08.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/20/2016] [Indexed: 01/24/2023]
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Postoperative complications in cardiac patients undergoing noncardiac surgery. Curr Opin Crit Care 2016; 22:357-64. [DOI: 10.1097/mcc.0000000000000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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