Hospital Volume and Postoperative Infections in Total Knee Arthroplasty

BackgroundThe purpose of this study was to evaluate the associations of hospital volume with revision surgery for infection and superficial incisional infections.MethodsA review of 12,541 primary total knee arthroplasties (TKAs) at a large integrated health system from 2014 to 2017 was conducted. Sixteen hospitals were classified as low-volume, medium-volume, or high-volume hospitals according to the mean number of TKAs/year (<250, 250-500, and >500, respectively). Thresholds were guided by percentiles and the literature on volume-outcome relationships. Medical records were reviewed for revision surgery for infection and superficial incisional infections during a mean 2-year review period. Multivariate analyses, adjusted for clinical and patient characteristics, were performed to evaluate the association between hospital volume and infection.ResultsThe overall rate of revision surgery for infection was 0.7% (n = 82), and the overall rate of superficial incisional infection was 2.6% (n = 324). After accounting for potential confounders, hospital volume was not found to have a significant association with revision surgery for infection when comparing high-volume and low-volume hospitals (odds ratio, 1.615; 95% confidence interval, 0.761-3.427; P = .212) as well as when comparing high-volume and medium-volume hospitals (odds ratio, 1.464; 95% confidence interval, 0.853-2.512; P = .166). Moreover, the risk of superficial incisional infection at high-volume hospitals was similar to that at low-volume (P = .107) and medium-volume (P = .491) hospitals.ConclusionInfection outcomes are quality metrics that are frequently used to compare hospitals including those of varying volumes. Using contemporary thresholds, this study found that infection rates after TKA at high-volume hospitals are comparable to low-volume and medium-volume hospitals.     

Prevalence,trend and disparities of palliative care utilization among hospitalized metastatic breast cancer patients who received critical care therapies

BackgroundEarly integration of palliative care (PC) for patients with advanced cancer has been recommended to improve quality of care. This study aims to describe prevalence, temporal trend and predictors of PC use in metastatic breast cancer (mBCa) patients receiving critical care therapies (CCT; included invasive mechanic ventilation, percutaneous endoscopic gastrostomy tube, total parenteral nutrition, tracheostomy and dialysis).MethodsThe National Inpatient Sample was queried for mBCa patients receiving CCT between 2005 and 2014. Annual percent changes (APC) were calculated for PC prevalence in the overall cohort and subgroups. Multivariable logistic analysis was used to explore predictors of PC use.ResultsOf 5833 mBCa patients receiving CCT, 880 (15.09%) received PC. Rate of PC use increased significantly from 2.53% in 2005 to 25.96% in 2014 (APC: 35.75%; p < 0.0001). Higher increase in PC use was observed in South (from 0.65% to 27.11%; APC: 59.42%; p < 0.0001), medium bedsize hospitals (from 3.75% to 26.05%; APC: 38.16%; p = 0.0006) and urban teaching hospitals (from 4.13% to 29.86%; APC: 37.33%; p = 0.0005). Multivariable analysis revealed that year interval, urban teaching hospitals, and invasive mechanical ventilation were associated with increased PC use, while primary diagnosis of gastrointestinal disorders, fractures, metastatic sites from lymph nodes and tracheostomy were associated with lower PC use.ConclusionsPC use in mBCa patients receiving CCT increases significantly over the period. However, it still remains low. Efforts to illustrate disparities in PC use are needed to improve quality of care for mBCa patients receiving CCT, especially for those hospitalized in rural and nonteaching hospitals.     

Volume-outcome relationship in halo vest utilization for C2 fractures

BACKGROUND CONTEXTThe prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions.PURPOSETo evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State.STUDY DESIGNRetrospective analysis of a statewide database.PATIENT SAMPLEWe queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected.OUTCOME MEASURESOutcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery.METHODSThe 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (>25 halos/year), medium-, (10–25 halos/year), or low-volume (<10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups: <40, 40 to 60, 60 to 80, and >80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p<.05 for all analyses.RESULTSIn all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p<.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p<.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients >80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60–79, 40–59, and <40, respectively; p<.01), mortality (14% vs. 5%, 1%, and 1% for groups 60–79, 40–59, and <40, respectively; p<.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60–79, 40–59, and <40, respectively; p<.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p<.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively).CONCLUSIONSHalo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.     

Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective

OBJECTIVE: Open appendicectomy is the traditional standard treatment for appendicitis. Laparoscopic appendicectomy is perceived as a procedure with greater potential for complications and longer operative times. This paper examines the hypothesis that unsupervised laparoscopic appendicectomy by surgical trainees is a safe and time-effective valid alternative. METHODS: Medical records, operating theatre records and histopathology reports of all patients undergoing laparoscopic and open appendicectomy over a 15-month period in two hospitals within an area health service were retrospectively reviewed. Data were analysed to compare patient features, pathology findings, operative times, complications, readmissions and mortality between laparoscopic and open groups and between unsupervised surgical trainee operators versus consultant surgeon operators. RESULTS: A total of 143 laparoscopic and 222 open appendicectomies were reviewed. Unsupervised trainees performed 64% of the laparoscopic appendicectomies and 55% of the open appendicectomies. There were no significant differences in complication rates, readmissions, mortality and length of stay between laparoscopic and open appendicectomy groups or between trainee and consultant surgeon operators. Conversion rates (laparoscopic to open approach) were similar for trainees and consultants. Unsupervised senior surgical trainees did not take significantly longer to perform laparoscopic appendicectomy when compared to unsupervised trainee-performed open appendicectomy. CONCLUSION: Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective.     

High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients

Background: The relationship between hospital volume and outcomes needs to be further elucidated for low-risk procedures such as surgical therapy of localized breast cancer. The objective of this investigation was to assess the relationship between hospital volume and outcomes for breast cancer surgery. Methods: A total of 233,247 patients who underwent breast-conserving therapy (BCT) and breast-ablative therapy (BAT) for localized breast cancer were extracted from 13 years (1988–2000) of the Nationwide Inpatient Samples. Hospital volume was classified as low (<30 cases/year), intermediate (≥ 30 to <70cases/year), and high (≥ 70 cases/year). Multiple linear and logistic regression analyses were used to assess the risk-adjusted association between hospital volume and outcomes. Results: In risk-adjusted analyses, patients operated on at low-volume hospitals were 3.04 (p = 0.03) times more likely to die after BCT compared with patients operated on at high-volume hospitals. Similarly, low-volume hospitals had a significantly higher likelihood of postoperative complications (odds ratio [OR] = 1.73, p = 0.01 for BCT; OR = 1.44, p < 0.001 for BAT) compared with high-volume hospitals. Compared with low-volume hospitals, length of hospital stay was significantly shorter and nonroutine patient discharge significantly lower for high-volume providers for both BCT and BAT (all p < 0.001). Patients were also significantly less likely to undergo BCT if operated on in a low- or intermediate-volume hospital compared with a high-volume provider (p < 0.001). Conclusions: High-volume hospitals had significantly lower nonroutine patient discharge, postoperative morbidity and mortality, shorter length of hospital stay, and higher likelihood of performing BCT. Referral of patients with localized breast cancer to high-volume hospitals may be justified.     

Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture

PurposeThis study aimed to address the relationship between surgeon volume and the risk of complications following surgeries of displaced intra-articular calcaneal fractures (DIACFs).MethodsWe retrospectively reviewed the medical records and the follow-up registers for patients who underwent open reduction and internal fixation with plate/screws in our center between January 2015 and June 2020. Surgeon volume was defined as the number of surgically treated calcaneal fractures within the past 12 months, and was dichotomized on basis of the optimal cut-off value. The outcome measure was the documented overall complications within 1 year after surgery. Four logistics regression models were constructed to examine the potential relationship between surgeon volume and complications.ResultsAmong 585 patients, 49 had documented complications, representing an overall rate of 8.4%. The overall complication rate was 20.0% (22/111) in patients operated on by the low-volume surgeons and 5.7% (27/474) by the high-volume surgeons, with a significant difference (p < 0.001). The 4 multivariate analyses showed steady and robust inverse volume-complication relationship, with OR ranging from 3.8 to 4.4. The restricted cubic splines adjusted for total covariates showed the non-linear fitting “L-shape” or “reverse J-shape” curve (p = 0.041), and the OR was reduced until 10 cases, beyond which the curve leveled.ConclusionsOur findings reflected the important role of maintaining necessary operative cases, potentially informing optimized surgical care management.     

The weekend effect in status epilepticus: a national cohort study

Higher mortality following admission to hospital at the weekend has been reported for several conditions. It is unclear whether this variation is due to differences in patients or their care. Status epilepticus mandates hospital admission and usually critical care: its study might provide new insights into the nature of any weekend effect. We studied 20,922 adults admitted to UK critical care with status epilepticus from 2010 to 2015. We used multiple logistic regression to evaluate the association between weekend admission and in-hospital mortality, comparing university hospitals with other hospitals. There were 2462 in-hospital deaths (12%). There was no difference in mortality after weekend admission to university hospitals, adjusted odds ratio (95%CI) 0.99 (0.84–1.16), p = 0.89. Mortality was less after weekend admission than after admissions Monday to Friday in hospitals not associated with a university, adjusted odds ratio (95%CI) 0.74 (0.64–0.87), p = 0.0001. There is no evidence that adults admitted to UK critical care at the weekend in status epilepticus are more likely to die than similar patients admitted during the week.     

Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?

BackgroundThis study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers.MethodsHemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining “high-volume” hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable.ResultsIn total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes.ConclusionA clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable.Level of EvidencePrognostic Level III.     

Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures

BackgroundA relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003.MethodsData from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125–299], and low [<125]) and surgeon volume categories (high [≥50] and low [<50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity.ResultsHigh-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year.ConclusionIn Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.     

Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994

Purpose: Little is known about the long-term growth and outcomes of vascular surgery procedures over time. Trends in the use of three major vascular surgery procedures by a general population—lower extremity arterial bypass (LEAB), carotid endarterectomy (CEA), and abdominal aortic aneurysm repair (AAA)—are described. The extent to which these procedures are being performed in low-, moderate-, and high-volume hospitals is examined. Methods: California hospital discharge records for LEAB, CEA, AAA, lower extremity angioplasty, coronary angioplasty, and coronary bypass surgery (CABG) were studied in all non-federal hospitals between 1982 and 1994. The data were age- and sex-adjusted to describe procedure growth. In-hospital mortality rates for LEAB, CEA, and AAA are related to overall hospital procedure volume, using logistic regression to control for risk factors and time trends. Results: Growth in the number of vascular procedures performed in California was modest between 1982 and 1994, with no age-adjusted growth. Lower extremity angioplasty grew considerably in the 1980s and has since plateaued. Annual in-hospital death rates declined for all procedures except ruptured AAA. Comparing the two 5-year periods of 1982–1986 and 1990–1994, in-hospital death rates decreased from 4.2% to 3.3% for LEAB, from 9.2% to 6.2% for unruptured AAA, and from 1.6% to 1.0% for CEA (p < 0.0001). The odds of dying for patients treated in high-volume hospitals for LEAB and CEA procedures compared with patients treated in hospitals performing fewer than 20 procedures in a year were 66.7% (p = < 0.0001) and 66.1% (p < 0.0001), respectively. For patients with ruptured and unruptured AAA procedures, the odds of dying in hospitals with at least 50 AAA procedures in a year were 49.1% (p < 0.0001) and 83.8% (p = 0.016), respectively, compared with the odds of dying in low-volume hospitals. Conclusions: In-hospital mortality rates for CEA, LEAB, and unruptured AAA have been significantly decreasing over time. Mortality is inversely related to hospital volume and directly related to patient age and emergency status. Mortality trends over time for ruptured AAA remains unchanged; however, mortality is less in high-volume hospitals. Coronary angioplasty (PTCA) has not had an impact on rates for LEAB. (J Vasc Surg 1998;28:45-58)     

Hospital coronary artery bypass graft surgery volume and patient mortality, 1998-2000

OBJECTIVE: To evaluate the association between annual hospital coronary artery bypass graft (CABG) surgery volume and in-hospital mortality. SUMMARY BACKGROUND DATA: The Leapfrog Group recommends health care purchasers contract for CABG services only with hospitals that perform >or=500 CABGs annually to reduce mortality; it is unclear whether this standard applies to current practice. METHODS: We conducted a retrospective analysis of the National Inpatient Sample database for patients who underwent CABG in 1998-2000 (n = 228738) at low (12-249 cases/year), medium (250-499 cases/year), and high (>or=500 cases/year) CABG volume hospitals. Crude in-hospital mortality rates were 4.21% in low-volume hospitals, 3.74% in medium-volume hospitals, and 3.54% in high-volume hospitals (trend P < 0.001). Compared with patients at high-volume hospitals (odds ratio 1.00, referent), patients at low-volume hospitals remained at increased risk of mortality after multivariable adjustment (odds ratio 1.26, 95% confidence interval = 1.15-1.39). The mortality risk for patients at medium-volume hospitals was of borderline significance (odds ratio 1.11, 95% confidence interval = 1.01-1.21). However, 207 of 243 (85%) of low-volume and 151 of 169 (89%) of medium-volume hospital-years had risk-standardized mortality rates that were statistically lower or comparable to those expected. In contrast, only 11 of 169 (6%) of high-volume hospital-years had outcomes that were statistically better than expected. CONCLUSIONS: Patients at high-volume CABG hospitals were, on average, at a lower mortality risk than patients at lower-volume hospitals. However, the small size of the volume-associated mortality difference and the heterogeneity in outcomes within all CABG volume groups suggest individual hospital CABG volume is not a reliable marker of hospital CABG quality.     

What are the results of laparoscopic re-operative rectal surgery?

IntroductionReoperative rectal surgery is challenging, performed selectively by experienced colorectal surgeons. The minimally invasive approach has not been well defined. This study reviewed the results of laparoscopy in this challenging setting.MethodsRetrospective analysis of patients who underwent trans-abdominal re-operative rectal surgery from 2010 to 2019 was performed.ResultsSeventy-eight patients [35 females (45%); BMI 25kg/m2) were included. Reasons for reoperation were recurrent cancer in 18 (43%) patients and anastomotic failure in 57 (73%). Twenty-two (28%) had laparoscopic surgery and 4 had attempted laparoscopy converted to laparotomy. A higher success rate was noted for laparoscopy with prior laparoscopic surgery. Benefits of laparoscopy included significant reduction in length of stay (6.7 vs 9.7 days, p = 0.012) and abdominal superficial surgical site infection (0% vs 25%, p < 0.001) and higher rate of achieving bowel continuity compared to laparotomy (77% vs 50%, p = 0.021)ConclusionsReoperative laparoscopic rectal surgery is safe and feasible in the context of a high-volume laparoscopic surgeon with substantial experience in redo proctectomies. It offers clear benefits including decreased surgical site infection rates and length of stay.     

Living-Donor Kidney Transplantation Performed in a Low-Volume Center by Visiting Surgeons From a High-Volume Center and Managed Clinically Solely by Nephrologists: 1-Year Outcomes

BackgroundLittle is known about the outcome of living-donor kidney transplantation (LDKT) performed in low-volume centers lacking the services of full-time transplant surgeons. This retrospective cohort study assessed the outcome of LDKT performed in a low-volume center by visiting transplant surgeons from a high-volume center and managed perioperatively by transplant nephrologists.MethodsWe compared Japanese adult patients who had no donor-specific antibodies and underwent LDKT between 2006 and 2015 either in a low-volume (n = 31) or high-volume (n = 481) center. In the low-volume center, visiting transplant surgeons from the high-volume center conducted LDKT and transplant nephrologists managed the recipients peri- and postoperatively. The primary outcome was the composite of infection, cardiovascular disease, or cancer during 1-year follow-up. The outcomes of the low- and high-volume centers were compared using 1:2 propensity score matching.ResultsAfter matching, 9 of 29 patients in the low-volume center (31.0%) and 16 of 58 patients in the high-volume center (27.6%) experienced the primary composite outcome (risk ratio = 1.13; 95% confidence interval, 0.57-2.23). There were no significant differences between the 2 groups in graft function at 1 year, all-cause graft loss, biopsy-proven rejection, and urological complications. However, the median duration of post-LDKT hospitalization was significantly longer in the low-volume center than in the high-volume center (23 and 16 days, respectively).ConclusionsAmong Japanese patients without preformed donor-specific antibodies, LDKT conducted at a low-volume center by visiting transplant surgeons from a high-volume center and managed clinically by transplant nephrologists was not associated with significantly higher risk of postoperative complications.     

Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction

Abstract

Previous studies of outcomes following abdominal-based breast reconstruction largely use data from single-centre/surgeon experience. Such studies are limited in evaluating the effect of operative volume on outcomes. Abdominal-based breast reconstructive procedures were identified in the 2009–2010 HCUP Nationwide Inpatient Sample. Outcomes included in-hospital microvascular complications in free flap cases (requiring exploration/anastomosis revision), procedure-related and total complications in all cases, and length of stay (LOS). High-volume hospitals were defined as 90th percentile of case volume or higher (>30 flaps/year). Univariate and multivariate analyses were performed to identify predictors of outcomes. Of the 4107 patients identified, mean age was 50.7 years; 71% were white, 68% underwent free flap reconstruction, and 25% underwent bilateral reconstruction. The total complication rate was 13.2%, and the microvascular complication rate was 7.0%. Mean LOS was 4.5 days. There were 436 hospitals; 59% of cases were performed at high-volume institutions. Patients at high-volume hospitals more often underwent free flap reconstruction compared to low-volume hospitals (82.4% vs 50.5%, p < 0.001). On unadjusted analysis, microvascular complication rates of 6.4% vs 8.2% were observed for high-volume compared to low-volume hospitals (p = 0.080). After adjusting for case-mix, high-volume hospitals were associated with a decreased likelihood of suffering a microvascular complication (OR = 0.71, p = 0.026), procedure-related complication (OR = 0.79, p = 0.033), or total complication (OR = 0.75, p = 0.004). The majority of cases nationwide are performed at a small number of high-volume hospitals. These hospitals appear to discharge patients earlier and have lower microvascular, procedure-related, and total complication rates when controlling for case-mix.     

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

IntroductionBreast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.MethodsA randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).ResultsThere were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).ConclusionsSimple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.     

No Influence of Surgical Volume on Patients’ Health-Related Quality of Life After Esophageal Cancer Resection

Background  Studies on factors that can counteract the negative impact of esophagectomy on patients’ health-related quality of life (HRQL) have been sparse. This study was undertaken to examine the question whether hospital or surgeon volume influences HRQL as evaluated 6 months after such surgery. Materials and Methods  A Swedish prospective, population-based cohort study of esophageal cancer patients treated surgically in 2001–2005 was conducted. All patients completed validated HRQL questionnaires, developed by EORTC, addressing general HRQL (QLQ-C30) and esophageal-specific symptoms (QLQ-OES18), 6 months postoperatively. Mean scores with 95% confidence intervals were calculated. Clinically relevant mean score differences (≥10) between groups were further analyzed in a linear regression model, adjusted for several potential confounders. Results  Some 355 patients were included (80% of eligible). No clinically relevant differences were found between low-volume (0–9 operations/year) and high-volume hospitals (>9 operations/year) or between low-volume (0–6 operations/year) and high-volume surgeons (>6 operations/year). Stratified analyses for tumor location did not reveal any differences between hospital or surgeon volume groups. Moreover, no material differences were found between the four individual high-volume hospitals. Conclusion  This study revealed no HRQL advantages of being treated at high-volume hospitals or by high-volume surgeons, as measured 6 months after esophageal cancer resection.     

Three different laparoscopic techniques for the management of iatrogenic ureteral injury: A multi-institutional study with medium-term outcomes

BackgroundExcellent success rates with short-term outcomes are noted for laparoscopic ureteral reconstruction (LUR) for iatrogenic ureteral injury. This multi-institutional study assessed the medium-term (>1 year) outcomes and compared three surgical techniques of LUR.MethodsPatients who underwent LUR at five tertiary hospitals between January 2007 and June 2016 were retrospectively analyzed. Patients with active abdominopelvic inflammatory disease, history of urothelial cancer, and tumor recurrence and those who received adjuvant chemotherapy or radiotherapy were excluded.ResultsThe success rates of LUR for 61 patients at 3 months postoperatively and at the last follow-up (at least 12 months postoperatively) were 100% and 95.1%, respectively. No significant difference was noted in the success rates of the three types of LUR. LUR was mainly performed in response to the demands of the primary surgeon responsible for the iatrogenic injury (33 of 45 cases, 73.3%). The vesicoureteral reflux (VUR) incidence was higher in the refluxing laparoscopic ureteroneocystostomy (LUN) group (40%) than in the anti-refluxing LUN group (15%, odds ratio: 1.5, p = 0.252). None of the patients in the LUN groups received treatment for VUR during the follow-up. The laparoscopic end-to-end ureteroureterostomy (LEEU) group had shorter operative time (p < 0.001) and lesser intraoperative blood loss (p < 0.001) than the LUN groups.ConclusionLUR is safe and feasible, with good medium-term outcomes. LEEU is a good surgical option in terms of the operative and subsequent outcomes. The anti-reflux technique in LUR reduces de-novo VUR development but is not necessary for preventing upper urinary tract infections in adults.     

The association of pre‐operative STOP‐BANG scores with postoperative critical care admission

The STOP‐BANG questionnaire screens for obstructive sleep apnoea. We retrospectively analysed the independent association of pre‐operative variables with postoperative critical care admission using multivariable logistic regression for patients undergoing elective surgery from January to December 2011. Of 5432 patients, 338 (6.2%) were admitted postoperatively to the critical care unit. In multivariate analysis, the odds ratios (95% CI) for critical care admission were: 2.2 (1.1–4.6), p = 0.037; 3.2 (1.2–8.1), p = 0.017; and 5.1 (1.8–14.9), p = 0.002, for STOP‐BANG scores of 4, 5 and ≥ 6, respectively. The odds ratio was also independently increased for: each year of age, 1.015 (1.004–1.026), p = 0.019; asthma, 1.6 (1.1–2.4), p = 0.016; obstructive sleep apnoea, 3.2 (1.9–5.6), p < 0.001; and for ASA physical status 2, 3 and ≥ 4, 2.1 (1.4–3.3), 6.5 (3.9–11.0), 6.3 (2.9–13.8), respectively, p < 0.001 for all.     

Recent Trends of Hepatic Resection in Canada: 1995–2004

Introduction  Recently, many surgical procedures have become regionalized in the United States, likely owing to research demonstrating a relationship between volume and outcome. We sought to describe patient characteristics and outcomes according to hospital volume along with patterns of regionalization for hepatic resection in Canada from 1995 to 2004. Methods  Discharge data from all hospitals across Canada except Quebec were obtained from the Canadian Institute for Health Information for 1995–2004. All patients undergoing a hepatic resection were identified using ICD-9 and ICD-10 codes. High-volume hospitals were defined as those performing ten or more procedures per year. Results  A total of 9,912 patients (mean age 59 years) underwent hepatic resection. The proportion of procedures performed at high-volume hospitals increased from 42% in 1995 to 84% in 2004. Overall mortality rate for the study period was 5.0% which decreased over time. Mortality rates were higher at low-volume (6.1%) compared to high-volume centers (4.6%), but this finding was not statistically significant (p = 0.7451). Those factors predictive of mortality in a multivariate analysis included age, gender, year of operation, operative indication, comorbidity score, and admission status. Discussion  Mortality rates have significantly improved. Hospital volume is not a significant predictor of mortality following liver resection in Canada. Presented in oral format at a Surgical Society of the Alimentary Tract Plenary Session of Digestive Disease Week, May 19, 2008, San Diego Convention Center, San Diego, CA, USA.     

Sources of regional and center-level variability in survival and cost of care for congenital diaphragmatic hernia (CDH)

PurposeEnormous variability in management and cost occurs in CDH care. The purpose of this study was to identify regional mortality and cost patterns underlying this variability.MethodsThis is a retrospective study of neonatal CDH patients at U.S. hospitals using data from the Pediatric Health Information System (PHIS) database (2015–2018). Patients were risk-stratified using CDH Study Group predicted survival (CDHSG-PS), and mortality and costs were assessed by region (East, West, Mid-West, and South) and center.ResultsHigher mortality and extracorporeal life support (ECLS) rates were found in the Mid-West and South (p < 0.0001). Higher mortality was seen with ECLS among low-volume centers in the South (p = 0.007). When broken down by CHDSG-PS, higher severity patients had higher mortality in the Mid-West and South (p = 0.038). Cost was significantly lower for high severity nonsurvivors than survivors ($244,005 vs $565,487, p = 0.0008). The East spent more on high-severity patients with lower mortality compared to other regions, but also spent 3.5 times more on low severity nonsurvivors than survivors. Costs were higher at high-volume centers for low- and medium-severity patients, but all centers spent the same on high-severity patients.ConclusionCenter volume, region, and patient severity all contribute to the complex survival and cost disparities that exist in CDH care. Standardization of care may improve survival and reduce cost variability.Type of studyRetrospective database study.Level of evidenceLevel II