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Cohen TN, Kanji FF, Zamudio J, Shouhed D, Gewertz BL, Sax HC. Why can't we improve turnover time? A systematic review. World J Surg 2024; 48:72-85. [PMID: 38686762 DOI: 10.1002/wjs.12015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention. MATERIAL AND METHODS A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline. RESULTS A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%). DISCUSSION There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.
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Affiliation(s)
- Tara N Cohen
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
| | - Falisha F Kanji
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
| | - Jennifer Zamudio
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
| | - Daniel Shouhed
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
| | - Bruce L Gewertz
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
| | - Harry C Sax
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California, USA
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2
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Cohen TN, Kanji FF, Wang AS, Seferian EG, Sax HC, Gewertz BL. Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. Am J Surg 2023; 226:315-321. [PMID: 37202268 DOI: 10.1016/j.amjsurg.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series. METHODS Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center. RESULTS Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%). CONCLUSIONS Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Andrew S Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Edward G Seferian
- Department of Medical Affairs, Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Bruce L Gewertz
- Department of Surgery, Interventional Services, Academic Affairs, Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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Daskivich TJ, Gewertz BL. Campaign Reform for US News and World Report Rankings. JAMA Surg 2023; 158:114-115. [PMID: 36383364 DOI: 10.1001/jamasurg.2022.4511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This Viewpoint discusses the perceived importance of US News and World Report hospital rankings and concerns with using specialty voting to dominate the assessment of process.
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Affiliation(s)
- Timothy J Daskivich
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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4
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Cohen TN, Anger JT, Shamash K, Catchpole KR, Avenido R, Ley EJ, Gewertz BL, Shouhed D. The Application of Human Factors Engineering to Reduce Operating Room Turnover in Robotic Surgery. World J Surg 2022; 46:1300-1307. [DOI: 10.1007/s00268-022-06487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/25/2022]
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5
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Cohen TN, Wang AS, Seferian EG, Sax HC, Gewertz BL. Assessment of Emotional Outcomes of Intraoperative Death on Surgical Team Members. JAMA Surg 2021; 156:683-685. [PMID: 33909005 DOI: 10.1001/jamasurg.2021.0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew S Wang
- Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward G Seferian
- Medical Affairs and Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Cohen TN, Griggs AC, Kanji FF, Cohen KA, Lazzara EH, Keebler JR, Gewertz BL. Advancing team cohesion: Using an escape room as a novel approach. Journal of Patient Safety and Risk Management 2021. [DOI: 10.1177/25160435211005934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective An escape room was used to study teamwork and its determinants, which have been found to relate to the quality and safety of patient care delivery. This pilot study aimed to explore the value of an escape room as a mechanism for improving cohesion among interdisciplinary healthcare teams. Methods This research was conducted at a nonprofit medical center in Southern California. All participants who work on a team were invited to participate. Authors employed an interrupted within-subjects design, with two pre- and post-escape room questionnaires related to two facets of group cohesion: (belonging – (PGC-B) and morale (PGC-M)). Participants rated their perceptions of group cohesion before, after, and one-month after the escape room. The main outcome measures included PGC-B/M. Results Sixty-two teams participated (n = 280 participants) of which 31 teams (50%) successfully “escaped” in the allotted 45 minutes. There was a statistically significant difference in PGC between the three time periods, F(4, 254) = 24.10, p < .001; Wilks’ Λ = .725; partial η2 = .275. Results indicated significantly higher scores for PGC immediately after the escape room and at the one-month follow-up compared to baseline. Conclusions This work offers insights into the utility of using an escape room as a team building intervention in interprofessional healthcare teams. Considering the modifiability of escape rooms, they may function as valuable team building mechanisms in healthcare. More work is needed to determine how escape rooms compare to more traditional team building curriculums.
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew C Griggs
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kate A Cohen
- Department of Enterprise Information Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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7
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Monica Jain
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
This article explores the role of human factors engineering in patient safety in surgery. The authors discuss the history and evolution of human factors and the role of human factors in patient safety and provide a description of human factors methods used to study and improve patient safety.
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8215, Los Angeles, CA 90048, USA
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8215, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, 8635 West Third Street, West Medical Office Tower, Suite 650-W, Los Angeles, CA 90048, USA.
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9
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Dhillon NK, Barmparas G, Lin TL, Linaval NT, Yang AR, Sekhon HK, Mason R, Margulies DR, Gewertz BL, Ley EJ. A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients. World J Surg 2020; 45:738-745. [PMID: 33169176 DOI: 10.1007/s00268-020-05849-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. STUDY DESIGN A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL. RESULTS There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01). CONCLUSION By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Ting Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Nikhil T Linaval
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Harveen K Sekhon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Russell Mason
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Bruce L Gewertz
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA.
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10
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Abstract
Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.
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Affiliation(s)
- Joshua Tseng
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harry C Sax
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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11
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Kuo S, Dhillon NK, Gewertz BL, Ley EJ. Surgical Cases in the COVID-19 Era : An Early Institutional Experience. Am Surg 2020; 86:560-561. [PMID: 32683971 DOI: 10.1177/0003134820925025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Susan Kuo
- 22494 Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- 22494 Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce L Gewertz
- 22494 Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- 22494 Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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12
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Shah A, Gupta N, Gewertz BL, Azizzadeh A. TEVAR for high risk patients with uncomplicated type B aortic dissection: a paradigm shift. Ital J Vasc Endovasc Surg 2020. [DOI: 10.23736/s1824-4777.20.01450-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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13
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Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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14
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Dhillon NK, Francis SE, Tatum JM, Keller M, Barmparas G, Gewertz BL, Ley EJ. Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit. JAMA Surg 2019; 153:1052-1053. [PMID: 30027268 DOI: 10.1001/jamasurg.2018.1752] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sarah E Francis
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James M Tatum
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle Keller
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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15
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Alban RF, Anania EC, Cohen TN, Fabri PJ, Gewertz BL, Jain M, Jopling JK, Maggio PM, Sanchez JA, Sax HC. Performance improvement in surgery. Curr Probl Surg 2019; 56:211-246. [PMID: 31155033 DOI: 10.1067/j.cpsurg.2019.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/06/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Monica Jain
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | - Juan A Sanchez
- St. Agnes Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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Alban RF, Anania EC, Cohen TN, Fabri PJ, Gewertz BL, Jain M, Jopling JK, Maggio PM, Sanchez JA, Sax HC. Performance improvement in surgery. Curr Probl Surg 2019; 56:204-208. [PMID: 31155032 DOI: 10.1067/j.cpsurg.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Monica Jain
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | - Juan A Sanchez
- St. Agnes Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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17
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Affiliation(s)
- Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Catherine Beni
- Department of Surgery, University of Washington, Seattle
| | - Nicholas Manguso
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Bruce L. Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Jain M, Gewertz BL. Surgical innovation as the driver of change in academic surgery. Surgery 2019; 166:717-720. [PMID: 30773219 DOI: 10.1016/j.surg.2018.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/17/2018] [Accepted: 11/27/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Monica Jain
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Abstract
The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify surgical near miss events reported via a hospital's event reporting system over the course of 1 year. Two trained analysts identified causal factors within each event narrative and subsequently categorized the events using HFACS-Healthcare. Of 910 original events, 592 could be analyzed further using HFACS-Healthcare, resulting in the identification of 726 causal factors. Most issues (n = 436, 60.00%) involved preconditions for unsafe acts, followed by unsafe acts (n = 257, 35.39%), organizational influences (n = 27, 3.72%), and supervisory factors (n = 6, 0.82%). These findings go beyond the traditional methods of trending incident data that typically focus on documenting the frequency of their occurrence. Analyzing near misses based on their underlying contributing human factors affords a greater opportunity to develop process improvements to reduce reoccurrence and better provide patient safety approaches.
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Dhillon NK, Smith EJ, Gillette E, Mason R, Barmparas G, Gewertz BL, Ley EJ. Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose? Int J Surg 2018; 51:128-132. [DOI: 10.1016/j.ijsu.2018.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 01/26/2023]
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21
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Dhillon NK, Ko A, Smith EJT, Kharabi M, Castongia J, Nurok M, Gewertz BL, Ley EJ. Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays. JAMA Surg 2017; 152:1015-1022. [PMID: 28724143 DOI: 10.1001/jamasurg.2017.2165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance High health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care. Objective To investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays. Design, Setting, and Participants This prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis. Interventions Based on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds. Main Outcomes and Measures Changes in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays. Results A total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P = .001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P < .001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ≤24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P < .001). Conclusions and Relevance Nearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J T Smith
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mayumi Kharabi
- Human-Centered Design Team, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph Castongia
- Human-Centered Design Team, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Nurok
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Dhillon NK, Smith EJT, Li T, Snodgrass K, Mason R, Barmparas G, Gewertz BL, Ley EJ. Titrating Heparin Infusions with Anti-Factor Xa Levels Decreases Dose Adjustments and Laboratory Draws in Surgical Patients. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ko A, Harada MY, Barmparas G, Chung K, Mason R, Yim DA, Dhillon N, Margulies DR, Gewertz BL, Ley EJ. Association Between Enoxaparin Dosage Adjusted by Anti-Factor Xa Trough Level and Clinically Evident Venous Thromboembolism After Trauma. JAMA Surg 2017; 151:1006-1013. [PMID: 27383732 DOI: 10.1001/jamasurg.2016.1662] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma patients are at high risk for developing venous thromboembolism (VTE). The VTE rate when enoxaparin sodium is dosed by anti-factor Xa (anti-Xa) trough level is not well described. Objective To determine whether targeting a prophylactic anti-Xa trough level by adjusting the enoxaparin dose would reduce the VTE rate in trauma patients. Design, Setting, and Participants Single-institution, historic vs prospective cohort comparison study at an urban, academic, level I trauma center. The prospective cohort was enrolled from August 2014 to May 2015 and compared with a historic cohort admitted from August 2013 to May 2014. Trauma patients who received enoxaparin adjusted by anti-Xa trough level (adjustment group) were compared with those who received enoxaparin sodium at a dosage of 30 mg twice daily (control group). Patients were excluded if they were younger than 18 years, had a length of hospital stay less than 2 days, or had preexisting deep vein thrombosis. Patients were excluded from the adjustment group for changes in the choice of thromboprophylaxis (heparin, enoxaparin once-daily dosing, early ambulation), hospital discharge before initial trough levels could be drawn, or incorrect timing of trough levels. Exposures Anti-Xa trough levels were monitored in patients in the adjustment group receiving 3 or more consecutive doses of enoxaparin sodium, 30 mg twice daily. Patients with a trough level of 0.1 IU/mL or lower received enoxaparin sodium increased by 10-mg increments. After providing 3 adjusted doses of enoxaparin, the trough level was redrawn and the dosage was adjusted as necessary. Patients in the control group received enoxaparin sodium at a dosage of 30 mg twice daily without adjustments. Main Outcomes and Measures Rates of symptomatic VTE (deep vein thrombosis and pulmonary embolism, confirmed by duplex ultrasonography and chest computed tomographic angiography, respectively) and bleeding risk. Results A total of 205 patients (mean [SD] age, 41.3 [18.2] years; 75.1% male) were studied, 87 in the adjustment group and 118 in the control group, with similar baseline characteristics and injury profiles. Subprophylactic anti-Xa troughs were noted in 73 of 87 patients (83.9%) in the adjustment group, and the majority of patients (57 of 87 patients [65.5%]) required dosage adjustment of enoxaparin sodium to 40 mg twice daily. Incidence of VTE was significantly lower in the adjustment group than in the control group (1.1% vs 7.6%, respectively; P = .046). When the adjustment group was compared with the control group, no significant difference was noted in the rate of packed red blood cell transfusion (6.9% vs 12.7%, respectively; P = .18) or mean (SD) hematocrit at discharge (34.5% [6.3%] vs 33.4% [6.8%], respectively [to convert to proportion of 1.0, multiply by 0.01]; P = .19). Conclusions and Relevance In this study, subprophylactic anti-Xa trough levels were common in trauma patients. Enoxaparin dosage adjustment may lead to a reduced rate of VTE without an increased risk of bleeding.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kevin Chung
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Russell Mason
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dorothy A Yim
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Barmparas G, Martin MJ, Wiegmann DA, Catchpole KR, Gewertz BL, Ley EJ. Increased Age Predicts Failure to Rescue. Am Surg 2016; 82:1073-1079. [PMID: 28206934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Failure to rescue (FTR), defined as any death after the development of in-hospital complications, is an important quality measure, but the relationship with age after a traumatic injury, has not been well defined. We sought to examine whether older trauma patients are at higher risk for FTR. The National Trauma Databank (NTDB) research datasets 2007 to 2011 were queried for patients ≥16 years who had any reported complication. Those who survived (non-FTR) were compared with those who did not (FTR) using a forward logistic regression model. Overall, 218,986 subjects met inclusion criteria of those, 201,358 (91.2%) survived their complication (non-FTR) and 17,628 (8.8%) died (FTR). A forward logistic regression identified age 65 to 89 years as the strongest predictor of FTR [adjusted odds ratio (AOR) 95% confidence interval (CI): 6.58 (6.11, 7.08), P < 0.001]. Using age group 16 to 45 years as the reference group, the adjusted risk for FTR increased with increasing age in a stepwise fashion [AOR (95 % CI): 1.94 (1.80, 2.09) for age 46 to 65 years, 6.78 (6.19, 7.42) for age 66 to 89 years and 27.58 [21.81, 34.87] for age ≥90 years]. The adjusted risk of FTR also increased in a stepwise fashion with increasing number of complications, reaching AOR (95 per cent CI) of 2.25 (2.07, 2.45), P < 0.001 for ≥4 complications. The risk of failure to rescue increases with age and number of complications. Strategies which track this quality measure to encourage early recognition and treatment of complications in the elderly are necessary.
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Affiliation(s)
- Galinos Barmparas
- Cedars-Sinai Medical Center, Department Of Surgery, Los Angeles, California, USA
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25
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Abstract
Failure to rescue (FTR), defined as any death after the development of in-hospital complications, is an important quality measure, but the relationship with age after a traumatic injury, has not been well defined. We sought to examine whether older trauma patients are at higher risk for FTR. The National Trauma Databank (NTDB) research datasets 2007 to 2011 were queried for patients ≥16 years who had any reported complication. Those who survived (non-FTR) were compared with those who did not (FTR) using a forward logistic regression model. Overall, 218,986 subjects met inclusion criteria of those, 201,358 (91.2%) survived their complication (non-FTR) and 17,628 (8.8%) died (FTR). A forward logistic regression identified age 65 to 89 years as the strongest predictor of FTR [adjusted odds ratio (AOR) 95% confidence interval (CI): 6.58 (6.11, 7.08), P < 0.001]. Using age group 16 to 45 years as the reference group, the adjusted risk for FTR increased with increasing age in a stepwise fashion [AOR (95 % CI): 1.94 (1.80, 2.09) for age 46 to 65 years, 6.78 (6.19, 7.42) for age 66 to 89 years and 27.58 [21.81, 34.87] for age ≥90 years]. The adjusted risk of FTR also increased in a stepwise fashion with increasing number of complications, reaching AOR (95 per cent CI) of 2.25 (2.07, 2.45), P < 0.001 for ≥4 complications. The risk of failure to rescue increases with age and number of complications. Strategies which track this quality measure to encourage early recognition and treatment of complications in the elderly are necessary.
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Affiliation(s)
- Galinos Barmparas
- Cedars-Sinai Medical Center, Department Of Surgery, Los Angeles, California
| | - Matthew J. Martin
- Madigan Army Medical Center, Department Of Surgery, Tacoma, Washington
| | | | - Ken R. Catchpole
- Cedars-Sinai Medical Center, Department Of Surgery, Los Angeles, California
| | - Bruce L. Gewertz
- Cedars-Sinai Medical Center, Department Of Surgery, Los Angeles, California
| | - Eric J. Ley
- Cedars-Sinai Medical Center, Department Of Surgery, Los Angeles, California
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Dhillon NK, Ko A, Harada M, Kharabi M, Castongia J, Nurok M, Gewertz BL, Ley EJ. Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Open repair of abdominal aortic aneurysms (AAAs) or occlusive disease can be complicated by pseudoaneurysm formation and aneurysmal dilatation of native vessels. Reports of reoperation for these new lesions have a mortality rate of 5–17% electively, and 24–88% if ruptured. These complications are commonly several years after initial repair, and progression of other comorbidities can further complicate a repeat exploration. The authors reviewed 5 cases of late complications of open aortic bypass surgery treated with endovascular stent grafting as an alternative to reexploration in patients with increased risk for morbidity and mortality. Over a 6-year experience, 5 patients underwent endovascular stent grafting to repair paraanastomotic aneurysms. Patient records were reviewed and clinical cardiac risk evaluation was performed. Follow-up clinic notes and computed tomography (CT) scans were evaluated. Between October 1996 and February 2002, 5 patients underwent 6 endovascular procedures to repair paraanastomotic aneurysms. Mean period between interventions was 16.6 ±6.27 years (range 10–25); mean age at endovascular procedure 74.2 ±6.37 years (range 67–84). Cardiac clinical risk index increased in 80% of patients by Goldman Risk Index and in 40% by the Modified Cardiac Risk Index. On completion angiography, there was complete exclusion of the paraanastomotic aneurysms in all cases (100%). Length of postoperative stay was 1.5 ±0.547 days. Mean estimated blood loss at conclusion of endovascular procedure was 577 ±546.504 cc (range, 60 cc–1,500 cc). Mean follow-up was 24.4 ±24.593 months (range, 5–67 months). On repeat imaging, all stent grafts remain patent without rupture or endoleak. Endovascular stent grafting to repair late complications of open AAA repair is a viable alternative to reexploration in patients with significant comorbidities. These procedures can be performed without violating the previous surgical planes of sites. The operations can be performed under local anesthesia and with reduced hospitalizations. In patients with increased risk factors, endovascular stent grafting is a less morbid alternative to open surgical techniques.
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Affiliation(s)
- Benjamin J Pearce
- Section of Vascular Surgery, University of Chicago Hospitals, Chicago, IL 60637, USA.
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Jain M, Fry BT, Hess LW, Anger JT, Gewertz BL, Catchpole K. Barriers to efficiency in robotic surgery: the resident effect. J Surg Res 2016; 205:296-304. [PMID: 27664876 DOI: 10.1016/j.jss.2016.06.092] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/06/2016] [Accepted: 06/26/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as "deviations from the natural progression of an operation," can help target training techniques and identify opportunities for improvement. MATERIALS AND METHODS Thirty-two robotic surgery operations were observed over a 6-wk period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration. RESULTS Twenty-one prostatectomies, eight sacrocolpopexies, and three nephrectomies were observed. The mean number of FDs was 48.2 (95% confidence interval [CI] 38.6-54.8 FDs), and mean operative duration was 163 min (95% CI 148-179 min). Each FD added 2.4 min (P = 0.025) to a case's total operative duration. The number and rate of FDs were significantly affected by resident involvement (P = 0.008 and P = 0.006, respectively). Resident cases demonstrated mostly training, equipment, and robot switch FDs, whereas nonresident cases demonstrated mostly equipment, instrument changes, and external factor FDs. CONCLUSIONS Although the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as equipment or external factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.
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Affiliation(s)
- Monica Jain
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Brian T Fry
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Luke W Hess
- Eberly College of Science, Pennsylvania State University, Pennsylvania
| | - Jennifer T Anger
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Ken Catchpole
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California; Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina.
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VonDerHaar RJ, Shah A, Nissen NN, Gewertz BL. Primary intra-aneurysmal surgical repair of a celiomesenteric trunk aneurysm. J Vasc Surg Cases 2015; 1:50-52. [PMID: 31724576 PMCID: PMC6849929 DOI: 10.1016/j.jvsc.2014.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 11/18/2014] [Indexed: 12/04/2022] Open
Abstract
We describe the surgical management of an asymptomatic 3-cm saccular aneurysm originating from a celiomesenteric trunk in a 45-year-old man. Surgical management was influenced by the location of the aneurysm, involving hepatic, splenic, and superior mesenteric arterial branches, by the young age of the patient, which made use of a synthetic graft less ideal, and by the lack of endovascular options.
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Affiliation(s)
- R Jason VonDerHaar
- Section of General Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Aamir Shah
- Section of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Nicholas N Nissen
- Section of Hepatobiliary Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Bruce L Gewertz
- Section of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
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Gangi A, Catchpole K, Blocker R, Blaha J, Shouhed D, Gewertz BL, Ley EJ. Human factors methods improve efficiency in emergency trauma care. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Blocker RC, Shouhed D, Gangi A, Ley E, Blaha J, Gewertz BL, Wiegmann DA, Catchpole KR. Barriers to Trauma Patient Care Associated with CT Scanning. J Am Coll Surg 2013; 217:135-41; discussion 141-3. [DOI: 10.1016/j.jamcollsurg.2013.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/22/2013] [Accepted: 03/22/2013] [Indexed: 11/30/2022]
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Catchpole KR, Gangi A, Blocker RC, Ley EJ, Blaha J, Gewertz BL, Wiegmann DA. Flow disruptions in trauma care handoffs. J Surg Res 2013; 184:586-91. [PMID: 23587454 DOI: 10.1016/j.jss.2013.02.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/15/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Effective handoffs of care are critical for maintaining patient safety and avoiding communication problems. Using the flow disruption observation technique, we examined transitions of care along the trauma pathway. We hypothesized that more transitions would lead to more disruptions, and that different pathways would have different numbers of disruptions. METHODS We trained observers to identify flow disruptions, and then followed 181 patients from arrival in the emergency department (ED) to the completion of care using a specially formatted PC tablet. We mapped each patient's journey and recorded and classified flow disruptions during transition periods into seven categories. RESULTS Mapping the transitions of care shows that approximately four of five patients were assessed in the ED, transferred to imaging for further diagnostics, and then returned to the ED. There was a mean of 2.2 ± 0.09 transitions per patient, a mean of 0.66 ± 0.15 flow disruptions per patient, and 0.31 ± 0.07 flow disruptions per transition. Most of these (53%) were related to coordination problems. Although disruptions did not rise with more transitions, patients who went directly to the operating room or needed direct admission to intensive care unit were significantly more likely (P=0.0028) to experience flow disruptions than those who took other, less expedited pathways. CONCLUSIONS Transitions in trauma care are vulnerable to systems problems and human errors. Coordination problems predominate as the cause. Sicker, time-pressured, and more at-risk patients are more likely to experience problems. Safety practices used in motor racing and other industries might be applied to address these problems.
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Affiliation(s)
- Ken R Catchpole
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Hadjibashi AA, Mirocha J, Cossman DV, Gewertz BL. Decreases in Diameters of Treated Abdominal Aortic Aneurysms and Reduction in Rupture Rate. JAMA Surg 2013; 148:72-5. [DOI: 10.1001/archsurg.2012.1151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Shouhed D, Catchpole K, Ley EJ, Blaha J, Blocker RC, Duff S, Karl C, Karl R, Gewertz BL, Wiegmann D. Flow disruptions during trauma care. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ourian AJ, Nasseri Y, Kohanzadeh S, Margulies DR, Gewertz BL, Chen SC, Towfigh S. Outreach in surgery at the undergraduate level: an opportunity to improve surgical interest among women? Am Surg 2011; 77:1412-1415. [PMID: 22127101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course ("Surgery 99") offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.
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Affiliation(s)
- Ariel J Ourian
- University of California, Irvine, School of Medicine, Irvine, California, USA
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Ourian AJ, Nasseri Y, Kohanzadeh S, Margulies DR, Gewertz BL, Chen SC, Towfigh S. Outreach in Surgery at the Undergraduate Level: An Opportunity to Improve Surgical Interest among Women?. Am Surg 2011. [DOI: 10.1177/000313481107701032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course (“Surgery 99”) offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.
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Affiliation(s)
- Ariel J. Ourian
- University of California, Irvine, School of Medicine, Irvine, California
| | - Yosef Nasseri
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Som Kohanzadeh
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Bruce L. Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steve C. Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shirin Towfigh
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Ng TT, Mirocha J, Magner D, Gewertz BL. Variations in the utilization of endovascular aneurysm repair reflect population risk factors and disease prevalence. J Vasc Surg 2010; 51:801-9, 809.e1. [DOI: 10.1016/j.jvs.2009.10.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 11/28/2022]
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Magner D, Mirocha J, Gewertz BL. Regional variation in the utilization of carotid endarterectomy. J Vasc Surg 2009; 49:893-901; discussion 901. [PMID: 19217747 DOI: 10.1016/j.jvs.2008.11.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 11/13/2008] [Accepted: 11/13/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE In different regions of the United States, highly variable rates have been documented for a wide range of procedures, such as prostatectomy and caesarean section. It is generally held that this variation is due to inconsistent physician practice patterns or other nonmedical considerations. Only limited research has been conducted regarding vascular surgical operations. We examined national data on the utilization of carotid endarterectomy (CEA) to determine the extent and diversity of regional variations. METHODS Medicare discharge data quantified the per capita rate of CEA in 50 states and the District of Columbia in 2003. Multiple metrics pertaining to risk factors, socioeconomic status, access to care, provider density, and local health care capacity were quantified. We performed bivariate analysis, Pearson (PC) or Spearman (SC) correlations, and multiple regression modeling. RESULTS In 2003, 83,164 CEAs were performed on 28,767,985 enrollees. CEA rates were 28.9 +/- 7.8 per 10,000 (range, 5.6-44.7 per 10,000). The rate of CEA was highly correlated with the number of heart disease deaths (PC = 0.575, P < .0001), deaths by stroke (PC = 0.504, P = .0002), and percentage of adult smokers in a state (PC = 0.643, P < .0001). These three factors held the strongest association with variation in CEA rates. Statistically, they explained 51% of the variation in total number of CEAs (R(2) = 0.5074, P < .0001). Median annual income (PC = -0.608, P < .0001) and percentage of college degrees (PC = -0.606, P < .0001) displayed inverse relationships to CEA rates. Per capita hospital beds (SC = 0.540, P < .0001) and rural health care clinics (SC = 0.518, P < .0001) exhibited positive correlations. The number of physicians or vascular surgeons did not predict higher utilization of CEA. CONCLUSION The strongest correlations for CEA were three markers associated with atherosclerotic disease: percentage of adult smokers and deaths from heart disease or stroke. Geographic variation in this vascular procedure is chiefly associated with variance in markers of disease prevalence, not physician preference or other nonmedical factors. The increased utilization of carotid stenting, accompanied by the participation of a much wider range of medical specialists, may affect this relationship in the future.
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Affiliation(s)
- David Magner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif, USA
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Affiliation(s)
- Bruce L Gewertz
- Department of Surgery, University of Chicago, Chicago, Ill, USA.
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Abstract
Microvascular dysfunction mediates many of the local and systemic consequences of ischemic-reperfusion (I/R) injury, with a spectrum of changes specific to arterioles, capillaries, and venules. This review discusses the specific changes in the endothelium during I/R injury; describes the differential responses of the various levels of the vasculature including arterioles, capillaries, and venules; and explores mechanisms for remote organ injury. Vascular dysfunction is largely a consequence of changes in the endothelial cells themselves, affecting the integrity of barrier function, cytokine and adhesion molecule expression, and vascular tone. The bioavailability of nitric oxide, an important mediator of vasodilation, is profoundly decreased during the reperfusion period, resulting in impaired vasodilation of arterioles. Release of inflammatory mediators and increased expression of adhesion molecules initiate inflammatory and coagulation cascades that culminate in the occlusion of capillaries, known as the "no-reflow''" phenomenon. In postcapillary venules, the recruitment and transmigration of leukocytes further compromise the integrity of the endothelial barrier and increase the oxidative burden, resulting in leakage and tissue edema. I/R injury can have significant and untoward consequences beyond the affected tissue, with such conditions as systemic inflammatory response syndrome. This review highlights recent progress in understanding of the varied phenomena of vascular dysfunction in I/R injury and some promising advances in the understanding and application of ischemic preconditioning and other potential therapies.
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Affiliation(s)
- John B Seal
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
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Baldwin ZK, Pearce BJ, Curi MA, Desai TR, McKinsey JF, Bassiouny HS, Katz D, Gewertz BL, Schwartz LB. Limb salvage after infrainguinal bypass graft failure. J Vasc Surg 2004; 39:951-7. [PMID: 15111843 DOI: 10.1016/j.jvs.2004.01.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed. METHODS This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years. RESULTS Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 +/- 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% +/- 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n = 16), 55% +/- 8% in patients with rest pain (n = 49), and 34% +/- 6% in patients with tissue loss (n = 73; P <.001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n = 25) carried a poor prognosis, with 2-year limb salvage of only 25% +/- 10%; limb salvage was 53% +/- 5% after intermediate graft failure (<2 years, n = 110) and 79% +/- 10% after late failure (>2 years, n = 15; P =.04). Multivariate analysis revealed shorter patency interval before failure (P =.006), use of warfarin sodium (Coumadin) postoperatively (P =.006), and infrapopliteal distal anastomosis (P =.01) as significant predictors for ultimate limb loss. CONCLUSION The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.
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Affiliation(s)
- Zachary K Baldwin
- Section of Vascular Surgery, Department of Surgery, University of Chicago, Chicago, Ill, USA
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Rossi PJ, Skelly CL, Meyerson SL, Bassiouny HS, Katz D, Schwartz LB, McKinsey JF, Gewertz BL, Desai TR. Redo infrainguinal bypass: factors predicting patency and limb salvage. Ann Vasc Surg 2003; 17:492-502. [PMID: 12958672 DOI: 10.1007/s10016-003-0040-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The increased complexity of redo infrainguinal bypass procedures can result in prolonged operative time and increased morbidity. This review was undertaken to compare outcomes from primary and redo bypass procedures and to identify factors predictive of graft failure and limb loss after redo bypass. All infrainguinal bypasses ( n = 468) from 1995 to 1999 were reviewed. A total of 367 primary bypasses in 317 patients were compared to 101 redo grafts in 84 patients with previously failed bypasses. Risk factors and types of procedures were compared using Student's t-test and the chi(2) test. Patency and limb salvage were compared using life-table analysis. Patients requiring redo bypasses were less likely to have diabetes and end-stage renal disease. Two-year patency (66 +/- 4% primary vs. 55 +/- 7% redo, p = 0.13) and limb salvage (75 +/- 3% primary vs. 72 +/- 6% secondary, p = 0.43) were comparable between primary and redo bypass groups. Female gender was predictive of redo graft failure (2-year patency 73 +/- 8% male vs. 39 +/- 9% female, p = 0.01). Clinical indications that predicted failure of a redo bypass included thrombosis of an autologous graft (1-year patency 71 +/- 7% previous prosthetic vs. 49 +/- 10% previous autologous, p = 0.004), thrombosis of an infrageniculate bypass (2-year patency 65 +/- 10% suprageniculate vs. 46 +/- 9% infrageniculate, p = 0.044), and a limb salvage indication for the primary operation (2-year patency 86 +/- 9% claudication vs. 44 +/- 8% limb salvage, p = 0.008). When a primary bypass fails despite the use of optimal conduit (autologous vein) and an infrageniculate target vessel, the redo bypass has a higher risk of failure, particularly in female patients. Nonetheless, patency and limb salvage rates justify an attempt at revascularization after failed primary bypass.
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Affiliation(s)
- Peter J Rossi
- Department of Surgery, Section of Vascular Surgery, The University of Chicago, Chicago, IL, USA
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46
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Curi MA, Skelly CL, Baldwin ZK, Woo DH, Baron JM, Desai TR, Katz D, McKinsey JF, Bassiouny HS, Gewertz BL, Schwartz LB. Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability. J Vasc Surg 2003; 37:301-6. [PMID: 12563199 DOI: 10.1067/mva.2003.114] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to test the hypothesis that the long-term outcome of infrainguinal bypass grafting in patients with congenital or acquired hypercoagulability is inferior to the results in patients without documented clotting disorders. METHODS The study was a retrospective analysis of consecutive patients from January 1994 to January 2001. RESULTS Five hundred eighty-two infrainguinal bypass grafts were created in 456 patients. Indication for surgery was limb-threatening ischemia in 84%; prosthetic conduits were implanted in 38%. Seventy-four grafts were created in 57 patients with one or more serologically proven hypercoagulable states, including heparin-induced platelet aggregation (n = 37), anticardiolipin antibodies (n = 11), lupus anticoagulant (n = 8), protein C or S deficiency (n = 7), antithrombin III deficiency (n = 3), and factor V Leiden mutation (n = 1). Patients with hypercoagulability were younger (63 +/- 2 years versus 69 +/- 1 years; P =.007), more likely to have undergone prior revascularization attempts (38% versus 21%; P =.003), and more likely to have chronic anticoagulation therapy after surgery (46% versus 25%; P =.001). After 5 years (median follow-up, 19 months), patients with hypercoagulability had poorer primary patency (28% +/- 7% versus 35% +/- 5%; P =.004), primary assisted patency (37% +/- 7% versus 45% +/- 6%; P =.0001), secondary patency (41% +/- 7% versus 53% +/- 6%; P =.0001), limb salvage (55% +/- 8% versus 67% +/- 6%; P =.009), and survival (61% +/- 8% versus 74% +/- 4%; P =.02) rates. Multivariate analysis identified only prosthetic conduit choice (P =.0001), hypercoagulability (P =.0003), and limb salvage indication (P =.01) as independent predictors of graft failure. CONCLUSION Patients with serologically proven hypercoagulability have inferior long-term patency, limb salvage, and survival rates after infrainguinal bypass. The high prevalence rate (13%) of diverse hypercoagulable states in this patient population supports serologic screening, especially in referral practices.
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Affiliation(s)
- Michael A Curi
- Section of Vascular Surgery, Department of Surgery, University of Chicago, IL 60637, USA
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Curi MA, Skelly CL, Woo DH, Desai TR, Katz D, McKinsey JF, Bassiouny HS, Gewertz BL, Schwartz LB. Long-term results of infrageniculate bypass grafting using all-autogenous composite vein. Ann Vasc Surg 2002; 16:618-23. [PMID: 12183773 DOI: 10.1007/s10016-001-0266-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Infrageniculate (below-knee) bypass using all-autogenous composite vein requires multiple incisions, venovenostomy, and prolonged operating time. The purpose of this study was to evaluate the long-term results of this procedure, with comparisons to grafts created from single-segment greater saphenous vein (GSV) or polytetrafluoroethylene (PTFE). A total of 362 consecutive infrainguinal bypass grafts with infrageniculate distal target arteries were created in 283 patients in a single institution between January 1995 and December 2000. Comorbid conditions were common, including diabetes (58%), coronary artery disease (56%), prior lower extremity revascularization (41%), end-stage renal failure (20%), and prior coronary artery bypass grafting (18%). The indication for revascularization was limb salvage in 93% of cases. The grafts were constructed from single segments of GSV (n = 239), from two or more vein segments resulting in an all-autogenous composite graft (n = 61), or from PTFE (n = 62). All-autogenous composite grafts were constructed using segments of ipsilateral or contralateral GSV (n = 49), upper extremity vein (n = 23), superficial femoral vein (n = 7), or lesser saphenous vein (n = 5). Infrageniculate all-autogenous composite vein grafts exhibited similar long-term results to those of GSV grafts, and far superior results to those of PTFE grafts. For patients with available autogenous segments, the all-autogenous composite vein graft is the conduit of choice.
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Affiliation(s)
- Michael A Curi
- Department of Surgery, Section of Vascular Surgery, University of Chicago, Chicago, IL, USA
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Abstract
Carotid artery angioplasty and stenting is gaining popularity, yet the natural history and optimal treatment for recurrent stenoses within stents are not known. Recurrent stenosis rates are not well characterized, with rates between 0 and 33% reported within the first year. Treatment of these lesions with repeat angioplasty may not be feasible or desirable, leading to operative interventions. We present two cases of asymptomatic high-grade in-stent restenosis treated successfully with carotid artery bypass using PTFE.
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Affiliation(s)
- Kellie R Brown
- Division of Vascular Surgery, The University of Chicago, Chicago, IL, USA.
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Curi MA, Skelly CL, Woo DH, Desai TR, Winterfield R, Gewertz BL, Schwartz LB. Spontaneous perforation of a non-aneurysmal visceral aorta. Cardiovasc Surg 2002; 10:279-83. [PMID: 12044438 DOI: 10.1016/s0967-2109(02)00009-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A 77 year-old woman with mild osteoarthritis and Sjögren's Syndrome presented to an outside hospital with mild abdominal and back pain. The initial computed tomography (CT) scan was essentially negative. The repeat CT scan after 1 week of medical therapy was suspicious for a contained rupture of the visceral aorta. She was emergently transferred to the University of Chicago. Emergent aortography confirmed the diagnosis and revealed wide patency of the visceral and renal arteries. Upon exploration, there was obvious rupture of the entire right posterior aortic wall at the level of the celiac axis with a large right retroperitoneal hematoma. Aorto-aortic bypass was performed. The visceral and renal vessels were revascularized using separate jump grafts to this 'parallel aorta'. The patient tolerated the procedure well and was discharged after 12 days. Pathologic examination of the aortic wall was essentially negative. She is well on follow-up after 20 months. To our knowledge, this is the second reported case of spontaneous contained rupture of the visceral aorta.
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Affiliation(s)
- Michael A Curi
- Department of Surgery, Section of Vascular Surgery, University of Chicago, Chicago, IL 60637, USA
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Abstract
BACKGROUND Elevated levels of interleukin-6 (IL-6) have been identified in a variety of systemic inflammatory states that are associated with endothelial barrier dysfunction, but the specific effect of IL-6 on endothelial permeability and the mechanism of action have not been fully examined. The current study evaluated the effect of IL-6 on endothelial permeability and on the distribution of the tight junctional protein ZO-1 and cytoskeletal actin. We also assessed the role of protein kinase C (PKC) in this process. METHODS Confluent monolayers of human umbilical vein endothelial cells (n = 6) were exposed to IL-6 (50-500 ng/ml) in the presence or absence of the PKC inhibitor Gö6976 (0.1 microM). Transendothelial electrical resistance (TEER) was measured at the onset of exposure and at 6-h intervals and compared with that of control cells using ANOVA with a Bonferroni multiple comparison test. Additional monolayers were exposed to IL-6, stained for ZO-1 and F-actin, and evaluated via fluorescence microscopy. RESULTS Interleukin-6 increased endothelial permeability as measured by TEER in a dose- and time-dependent manner. In the presence of PKC inhibitor, the IL-6-mediated increase in permeability was attenuated (18-h TEER 73% of control with IL-6 exposure vs 95% of control with IL-6 + Gö6976 inhibitor, P < 0.01). Microscopy revealed that permeability changes were accompanied by a redistribution of the tight junctional protein ZO-1 and cytoskeletal actin, increased cell contraction, and disorganization of the intercellular borders. Conclusions. The inflammatory cytokine IL-6 is an important mediator of increased endothelial permeability via alterations in the ultrastructural distribution of tight junctions and morphologic changes in cell shape. PKC is a critical intracellular messenger in these IL-6-mediated changes. A better understanding of this mechanism should allow the determination of rational treatment strategies for endothelial barrier dysfunction which occurs in inflammatory states.
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Affiliation(s)
- Tina R Desai
- Department of Surgery, University of Chicago, Chicago, Illinois 60637, USA.
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