Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.     

Evaluation of Hepato-Pancreato-Biliary (HPB) fellowships: an international survey of programme directors

Objectives

This report describes a survey undertaken with the aim of assessing the current status of available fellowships in hepatopancreatobiliary (HPB) surgery in order to identify steps to be taken to ensure the provision of successful training in this specialty.

Methods

An online survey was conducted among members of the International Hepato-Pancreato-Biliary Association (IHPBA) targeting registered and non-registered HPB surgery fellowships. A total of 71 programmes are registered on the IHPBA website and 40 fellowship directors completed the survey. Only 18 completed surveys referred to programmes previously listed on the website.

Results

Responses showed great diversity among centres regarding their requirements for application, the duration of training and exposure to HPB cases during the fellowship. Factors associated with higher levels of training included the country of fellowship, a third year of training and the presence of a well-structured HPB curriculum. Over 90% of responders seek official accreditation from their regional association (i.e. the European, American and Asian-Pacific HPB Associations). Most programmes would welcome official IHPBA or regional association monitoring of their fellowship.

Conclusions

This survey discloses important information which will allow the IHPBA Education and Training Committee to move forward. The next steps should include close monitoring of the performance of fellows by creating a fellows'' registry, as well as a blog or forum which can be used to further enhance communication among fellows. The availability of registration to both programme directors and fellows may eventually lead to an official fellowship accreditation process.     

Influence of aberrant right hepatic artery on perioperative course and longterm survival after pancreatoduodenectomy

Objectives

An aberrant right hepatic artery (aRHA) is the most frequently encountered vascular anomaly during pancreatoduodenectomy (PD). This study was performed to investigate the incidence of aRHA in a large series of PDs and to explore its relationship with complications and survival.

Methods

In a consecutive series of 790 PDs, aRHA could be identified or ruled out in 758 patients by reviewing operation reports. Patients with and without aRHA were compared. Main outcome measures were complications and survival (only in patients with a malignancy).

Results

The aRHA group consisted of 143 patients (19%). Characteristics of patients in the aRHA and normal RHA groups were comparable. There were no differences in surgical complications. The aRHA was preserved without damage in 130 patients (91%). Two patients in whom the aRHA was either sacrificed or damaged suffered complications (haemorrhage and intra-abdominal abscess in the right upper quadrant) that may have been related. Longterm survival in patients with a malignancy and an aRHA was not compromised.

Conclusions

An aRHA is frequently encountered during PD. Preservation is generally feasible without compromising survival in patients with malignant tumours. Surgical morbidity is not higher in patients with an aRHA. Preservation is technically possible in most patients and does not negatively impact on outcomes.     

Incorporating an HPB fellowship does not diminish surgical residents' HPB experience in a high-volume training centre

Background:

Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents'' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents'' HPB experience.

Methods:

Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared.

Results:

No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation (P= 0.003); however, exceeded the national average in each year except 2006. Graduating residents'' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation.

Discussion:

An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.     

Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND:

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE:

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS:

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS:

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS:

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.     

Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training

BACKGROUND

Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.

AIM

To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.

SETTING

A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.

PARTICIPANTS

Residents, faculty, and administrative staff.

PROGRAM DESCRIPTION

Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.

PROGRAM EVALUATION

A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).

DISCUSSION

A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2387-3) contains supplementary material, which is available to authorized users.KEY WORDS: ambulatory training, 4 + 1 model     

Centre volume and resource consumption in liver transplantation

Background

Using SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown.

Methods

Using the UHC database (2009–2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality.

Results

In all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC ($90 946 vs. $98 055 and $101 014, respectively, P < 0.0001); this effect persisted when adjusted for severity of illness.

Conclusions

This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation.     

A survey in the hepatopancreatobiliary community on ways to enhance patient recovery

Objectives

Both laparoscopic techniques and multimodal enhanced recovery programmes have been shown to improve recovery and reduce length of hospital stay. Interestingly, evidence-based care programmes are not widely implemented, whereas new, minimally invasive surgical procedures are often adopted with very little evidence to support their effectiveness. The present survey aimed to shed light on experiences of the adoption of both methods of optimizing recovery.

Methods

An international, web-based, 18-question, electronic survey was composed in 2010. The survey was sent out to 673 hepatopancreatobiliary (HPB) centres worldwide in June 2010 to investigate international experiences with laparoscopic liver surgery, fast-track recovery programmes and surgery-related equipoise in open and laparoscopic techniques and to assess opinions on strategies for adopting laparoscopic liver surgery in HPB surgical practice.

Results

A total of 507 centres responded (response rate: 75.3%), 161 of which finished the survey completely. All units reported performing open liver resections, 24.2% performed open living donor resections, 39.1% carried out orthotopic liver transplantations, 87.6% had experience with laparoscopic resections and 2.5% performed laparoscopic living donor resections. A median of 50 (range: 2–560) open and 9.5 (range: 1–80) laparoscopic liver resections per surgical unit were performed in 2009. Patients stayed in hospital for a median of 7 days (range: 2–15 days) after uncomplicated open liver resection and a median of 4 days (range: 1–10 days) after uncomplicated laparoscopic liver resection. Only 28.0% of centres reported having experience with fast-track programmes in liver surgery. The majority considered the instigation of a randomized controlled trial or a prospective register comparing the outcomes of open and laparoscopic techniques to be necessary.

Conclusions

Worldwide dissemination of laparoscopic liver resection is substantial, although laparoscopic volumes are low in the majority of HPB centres. The adoption of enhanced recovery programmes in liver surgery is limited and should be given greater attention.     

Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy?

Objectives:

Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). This study aimed to assess whether isolated Roux loop pancreaticojejunostomy (IPJ) is superior to conventional pancreaticojejunostomy (CPJ).

Methods:

Between September 2003 and July 2007, we performed 108 PDs. All patients underwent classical Kausch–Whipple PD with pancreaticojejunostomy (PJ). Patients were divided into two groups based on the type of PJ. Patients in group 1 underwent IPJ and those in group 2 underwent CPJ. A retrospective analysis of prospectively maintained data was performed to compare outcomes in the two groups.

Results:

There were 53 patients in group 1 and 55 in group 2. The two groups were comparable in both pre- and intraoperative parameters. The overall incidence of PF was 10.1% (five cases in group 1 vs. six in group 2). The course of clinically significant PF was similar in both groups in terms of fistula behaviour, management and the duration of spontaneous closure. Two patients in each group died. Overall complications, mortality and length of hospital stay were also similar; however, duration of surgery was significantly higher in group 1 vs. group 2 (442 min and 370 min, respectively; P= 0.005).

Conclusions:

Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.     

Role-Modeling Cost-Conscious Care—A National Evaluation of Perceptions of Faculty at Teaching Hospitals in the United States

BACKGROUND

Little is known about how well faculty at teaching hospitals role-model behaviors consistent with cost-conscious care.

OBJECTIVE

We aimed to evaluate whether residents and program directors report that faculty at their program consistently role-model cost-conscious care, and whether the presence of a formal residency curriculum in cost-conscious care impacted responses.

DESIGN

Cost-conscious care surveys were administered to internal medicine residents during the 2012 Internal Medicine In-Training Examination and to program directors during the 2012 Association of Program Directors in Internal Medicine Annual Survey. Respondents stated whether or not they agreed that faculty in their program consistently role-model cost-conscious care. To evaluate a more comprehensive assessment of faculty behaviors, resident responses were matched with those of the director of their residency program. A multivariate logistic regression model was fit to the outcome variable, to identify predictors of responses that faculty do consistently role-model cost-conscious care from residency program, resident, and program director characteristics.

PARTICIPANTS

Responses from 12,623 residents (58.4 % of total sample) and 253 program directors (68.4 %) from internal medicine residency programs in the United States were included.

MAIN MEASURES

The primary outcome measure was responses to questionnaires on faculty role-modeling cost-conscious care.

KEY RESULTS

Among all responses in the final sample, 6,816 (54.0 %) residents and 121 (47.8 %) program directors reported that faculty in their program consistently role-model cost-conscious care. Among paired responses of residents and their program director, the proportion that both reported that faculty do consistently role-modeled cost-conscious care was 23.0 % for programs with a formal residency curriculum in cost-conscious care, 26.3 % for programs working on a curriculum, and 23.7 % for programs without a curriculum. In the adjusted model, the presence of a formal curriculum in cost-conscious care did not have a significant impact on survey responses (odds ratio [OR], 1.04; 95 % Confidence Interval [CI], 0.52–2.06; p value [p] = 0.91).

CONCLUSIONS

Responses from residents and program directors indicate that faculty at US teaching hospitals were not consistently role-modeling cost-conscious care. The presence of a formal residency curriculum in cost-conscious care did not impact responses. Future efforts should focus on placing more emphasis on faculty development and on combining curricular improvements with institutional interventions to adapt the training environment.KEY WORDS: cost-conscious care, high-value , role-modeling, resident, program director, residency program, teaching hospitals, faculty, medical education     

Prophylactic octreotide for pancreatoduodenectomy: more harm than good?

Background

Most accrued evidence regarding prophylactic octreotide for a pancreatoduodenectomy (PD) predates the advent of the International Study Group of Pancreatic Fistula (ISGPF) classification system for a post-operative pancreatic fistula (POPF), and its efficacy in the setting of high POPF risk is unknown. The Fistula Risk Score (FRS) predicts the risk and impact of a clinically relevant (CR)-POPF and can be useful in assessing the impact of octreotide in scenarios of risk.

Methods

From 2001–2013, 1018 PDs were performed at four institutions, with octreotide administered at the surgeon’s discretion. The FRS was used to analyse the occurrence and burden of POPF across various risk scenarios.

Results

Overall, 391 patients (38.4%) received octreotide. A CR-POPF occurred more often when octreotide was used (21.0% versus 7.0%; P < 0.001), especially when there was advanced FRS risk. Octreotide administration also correlated with an increased hospital stay (mean: 13 versus 11 days; P < 0.001). Regression analysis, controlling for FRS risk, demonstrated that octreotide increases the risk for CR-POPF development.

Conclusion

This multi-institutional study, using ISGPF criteria, evaluates POPF development across the entire risk spectrum. Octreotide appears to confer no benefit in preventing a CR-POPF, and may even potentiate CR-POPF development in the presence of risk factors. This analysis suggests octreotide should not be utilized as a POPF mitigation strategy.     

Temporal trends in liver transplant centre volume in the USA

Background:

Although prior studies have suggested an inverse association between liver transplant centre volume and postoperative patient mortality, more recent analyses have failed to confirm this association. To date, all studies of the relationship between centre volume and outcomes in liver transplantation have been cross-sectional in design.

Objective:

The objective of our study was to examine temporal trends in the volume–outcomes relationship for liver transplantation.

Methods:

We used information obtained from the Scientific Registry of Transplant Recipients (SRTR) programme-specific data reports to examine the outcomes of adult liver transplant recipients stratified by annual centre volume. This relationship between centre volume and patient outcomes was assessed over three consecutive time periods from 2000 through 2007.

Results:

The overall 25% increase in adult liver transplant volume in the USA from 2000 to 2007 appeared to be distributed fairly equally among existing transplant centres. In the earliest time period of our analysis, high-volume centres achieved superior risk-adjusted 1-year patient outcomes compared with low-volume centres. By the third and most recent time period of the analysis, this discrepancy between the outcomes of high- and low-volume centres was no longer statistically apparent.

Conclusions:

The relationship between centre volume and patient outcomes for liver transplantation in the USA has become less pronounced over time, suggesting that the use of procedure volume as a marker of liver transplant centre quality cannot be justified. The performance-based review process currently utilized in the USA may have contributed to this diminishing influence of centre volume on liver transplant recipient outcomes. This type of review process should be considered as a potential alternative to the volume-based referral initiatives that have been developed for other non-transplant, complex surgical procedures.     

The effects of lifestyle modification on symptoms and quality of life in patients with irritable bowel syndrome: a prospective observational study

Background/Aims

Although notably common, irritable bowel syndrome (IBS) has no specific cure. Lifestyle modification may be as important as medication; however, few studies support the effectiveness of such modifications. We performed this observational study of IBS patients to explore further the role of lifestyle changes in treatment.

Methods

This study included 831 men who enlisted in 2010 as armed surgeon cadets and 85 women who concurrently entered the Armed Forces Nursing Academy. Of these 916 participants, 89 were diagnosed with IBS using the Rome III criteria. Subjective changes in bowel habits, quality of life, pain, stress, stool frequency and stool consistency were surveyed before and after 9 weeks of army training. We evaluated the lifestyle risk factors that impacted improvement in IBS symptoms by comparing those who responded to lifestyle modification (the responding group) to those who did not respond (the nonresponding group).

Results

More than half of the participants (63%) reported that their symptoms improved after training. The quality of life and levels of pain and stress significantly improved after military training. Initial stress levels before military training and smoking history affected IBS symptom improvement.

Conclusions

Lifestyle modification may be effective in managing IBS patients.     

Improvements in professional competence at secondary versus tertiary hospitals: a cross-sectional study of the standardised residency training programme in Shanghai,China

Background

Secondary hospitals in Shanghai received less support for conducting medical residency programmes than tertiary hospitals, until the programmes became standardised in 2010. If standardisation succeeds, it may reduce the disparities in the quality of the physician workforce and health care among different hospitals. This study examined whether residents at secondary hospitals had the same perception of the magnitude of their improvement in competence as those at tertiary hospitals after standardised residency training.

Opportunity costs of gastrointestinal endoscopic training in Canada

BACKGROUND

No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards.

OBJECTIVE

To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training.

METHODS

Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data.

RESULTS

Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration.

CONCLUSIONS

Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.     

Icodextrin Increases Technique Survival Rate in Peritoneal Dialysis Patients with Diabetic Nephropathy by Improving Body Fluid Management: A Randomized Controlled Trial

Summary

Background and objectives

There are still controversies whether peritoneal dialysis (PD) with icodextrin preserves residual renal and peritoneal membrane functions in patients with diabetes. However, there are no randomized controlled and long-term clinical trials in newly started PD patients with diabetic nephropathy.

Design, setting, participants, & measurements

Forty-one patients with diabetic nephropathy with ESRD were enrolled and randomly assigned to the glucose group (GLU) treated with 8 L of 1.5% or 2.5% glucose or an icodextrin group (ICO) treated with 1.5 or 2.0 L of 7.5% icodextrin-containing solutions. Technique failure, body fluid management, glucose and lipid metabolism, and residual renal and peritoneal functions and were evaluated over 2 years.

Results

The technique survival rate was 71.4% in ICO and 45.0% in GLU, with most of the technique failure due to volume overload. ICO showed significantly better cumulative technique survival. Net ultrafiltration volume was significantly higher in ICO throughout the study period. There were no beneficial effects of icodextrin on hemoglobin A1c, glycoalbumin, and lipid profile at 24 months. Urine volume and residual renal function declined faster in ICO, but there were no significant differences between the two groups. For peritoneal function, no differences were observed in dialysis-to-plasma creatinine ratios during the observation.

Conclusions

In PD therapy for diabetic nephropathy, the use of icodextrin-containing solutions has a beneficial effect on technique survival, but there are no apparent benefits or disadvantages in residual renal and peritoneal functions compared with conventional PD with glucose solution.     

Hepatitis C as a prognostic indicator among noncirrhotic patients hospitalized with alcoholic hepatitis

OBJECTIVE:

A nationwide analysis of alcoholic hepatitis (AH) admissions was conducted to determine the impact of hepatitis C virus (HCV) infection on short-term survival and hospital resource utilization.

METHODS:

Using the Nationwide Inpatient Sample, noncirrhotic patients admitted with AH throughout the United States between 1998 and 2006 were identified with diagnostic codes from the International Classification of Diseases, Ninth Revision. The in-hospital mortality rate (primary end point) of AH patients with and without co-existent HCV infection was determined. Hospital resource utilization was assessed as a secondary end point through linear regression analysis.

RESULTS:

From 1998 to 2006, there were 112,351 admissions for AH. In-hospital mortality was higher among patients with coexistent HCV infection (41.1% versus 3.2%; P=0.07). The adjusted odds of in-hospital mortality in the presence of HCV was 1.48 (95% CI 1.10 to 1.98). Noncirrhotic patients with AH and HCV also had longer length of stay (5.8 days versus 5.3 days; P<0.007) as well as greater hospital charges (US$25,990 versus US$21,030; P=0.0002).

CONCLUSIONS:

Among noncirrhotic patients admitted with AH, HCV infection was associated with higher in-hospital mortality and resource utilization.