RESUMEN
INTRODUCTION: Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps. METHODS: ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts. RESULTS: Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing. CONCLUSIONS: Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.
Asunto(s)
Equipos Desechables , Equipo Reutilizado , Equipo Reutilizado/normas , Humanos , Huella de Carbono , Fibra de Algodón/análisis , Paños Quirúrgicos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiologíaRESUMEN
INTRODUCTION: Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons. METHODS: Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis. RESULTS: Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position. CONCLUSIONS: Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.
Asunto(s)
Internado y Residencia , Cirujanos , Humanos , Determinantes Sociales de la Salud , Actitud del Personal de Salud , Cirujanos/educación , Encuestas y CuestionariosRESUMEN
INTRODUCTION: The introduction of minimally invasive surgery (MIS) for repair of congenital diaphragmatic hernias (CDH) has reduced postoperative length of stay, postoperative opioid consumption, and provided a more esthetic repair. In adult abdominal surgery, minimally invasive techniques have been associated with decreased long-term rates of small bowel obstruction (SBO), although it is unclear if this benefit carries over into the pediatric population. Our objective was to evaluate the rates of SBO following open versus MIS CDH repair. MATERIAL AND METHODS: Infants who underwent CDH repair between 2010 and 2021 were identified using the PearlDiver Mariner database. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate time to SBO by surgical approach (MIS versus open) while adjusting for mesh use, patient sex, and length of stay. RESULTS: Of 1033 patients that underwent CDH repair, 258 (25.0%) underwent a minimally invasive approach. The overall rate of SBO was 7.5% (n = 77). Rate of SBO following MIS repair was lower than open repair at 1 y (0.8% versus 5.1%), 3 y, (2.3% versus 9.0%), and 5 y (4.4% versus 10.1%, P = 0.004). Following adjustment, the rate of SBO following MIS repair remained significantly lower than open repair (adjusted hazard ratio: 0.37, 95% confidence interval: 0.18, 0.79). CONCLUSIONS: Following CDH repair, long-term rates of SBO are lower among patients treated with MIS approaches. Long-term risk of SBO should be considered when selecting surgical approach for CDH patients.
Asunto(s)
Hernias Diafragmáticas Congénitas , Obstrucción Intestinal , Lactante , Humanos , Niño , Resultado del Tratamiento , Hernias Diafragmáticas Congénitas/cirugía , Herniorrafia/efectos adversos , Herniorrafia/métodos , Obstrucción Intestinal/epidemiología , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Estudios RetrospectivosRESUMEN
BACKGROUND: The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes. METHODS: This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes. RESULTS: Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73). CONCLUSIONS: Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.
Asunto(s)
Complicaciones Posoperatorias , Determinantes Sociales de la Salud , Humanos , Determinantes Sociales de la Salud/estadística & datos numéricos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Anciano , Adulto , Readmisión del Paciente/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Mejoramiento de la CalidadRESUMEN
BACKGROUND: Refinement of surgical preference cards may reduce waste from surgery. This study aimed to characterize surgeon perceptions and practices regarding preference card maintenance, identify barriers to updating preference cards, and explore whether opinions on environmental stewardship relate to preference card maintenance. METHODS: This was a mixed methods survey performed at a single tertiary academic medical center. Surgeons completed questions on accuracy, frequency of updates, and perceived environmental impact of their preference cards. Responses were compared between early career and mid-to late-career surgeons using Kruskal-Wallis, chi-squared, and Fisher's exact tests. RESULTS: The response rate was 46.4% (n = 89/192). Among respondents, 46.1% (n = 41/89) rarely or never updated preference cards. Nearly all (98.9%, n = 87/88) said some of their cases had unused items on their cards. Most (87.6%, n = 78/89) made updates via verbal requests. Unfamiliar processes (83.7%, n = 72/86) and effort required (64.0%, n = 55/86) were viewed as barriers to card maintenance. Most agreed that more frequent updates would reduce waste (80.5%, n = 70/87), but respondents did not feel knowledgeable about the environmental impact of items on their cards (62.1%, n = 54/87). Mid-to late-career surgeons were less likely to update their cards annually or more often compared to early career surgeons (18.9%, n = 7/37 vs. 57.1%, n = 24/42, p < 0.001). No other responses varied significantly between early career and mid-to late-career surgeons. CONCLUSIONS: Surgeons acknowledged the utility of preference card maintenance in environmental stewardship, but unfamiliar systems and perceived effort hindered preference card review. Greater attention to preference card maintenance would promote environmentally sustainable practices in surgery.
RESUMEN
Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.
Asunto(s)
Neumotórax , Adolescente , Niño , Humanos , Toma de Decisiones Clínicas , Neumotórax/terapiaRESUMEN
BACKGROUND: Pilonidal disease is classically treated with wide local excision, although a number of minimally invasive approaches are currently under investigation. We aimed to determine the safety and feasibility of laser ablation of pilonidal sinus disease. IMPACT OF INNOVATION: Laser ablation provides a minimally invasive means of obliterating pilonidal sinus tracts without a need for excessive tract dilation. Laser ablation can be performed more than once on the same patient if necessary. TECHNOLOGY MATERIALS AND METHODS: This technique uses the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe. We performed laser ablation in adults and pediatric patients. PRELIMINARY RESULTS: We performed 27 laser ablation procedures in 25 patients, with a median operative time of 30 minutes. Eighty percent of patients reported either no pain or mild pain at the 2-week postoperative visit. The median time to return to work or school was 3 days. Eighty-eight percent of patients reported being satisfied or very satisfied with the procedure at their most recent follow-up (median, 6 mo). Eighty-two percent of patients were healed at 6 months. CONCLUSIONS AND FUTURE DIRECTIONS: Laser ablation of pilonidal disease is safe and feasible. Patients experienced short recovery time and reported low levels of pain and high levels of satisfaction.
Asunto(s)
Terapia por Láser , Seno Pilonidal , Enfermedades de la Piel , Adulto , Humanos , Niño , Resultado del Tratamiento , Proyectos Piloto , Seno Pilonidal/cirugía , Dolor PostoperatorioRESUMEN
INTRODUCTION: The operating room (OR) is a major contributor to greenhouse gas emissions both nationally and globally. Successful implementation of quality improvement initiatives requires understanding of key stakeholders' perspectives of the issues at hand. Our aim was to explore surgical, anesthesia, and OR staff member perspectives on barriers and facilitators to reducing OR waste. MATERIALS AND METHODS: Identified stakeholders from a single academic medical center were interviewed to identify important barriers and facilitators to reducing surgical waste. Two team members with qualitative research experience used deductive logic guided by the Theoretical Domains Framework of behavior change to identify themes within transcripts. RESULTS: Nineteen participants including surgeons (n = 3, 15.8%), surgical residents (n = 5, 26.3%), an anesthesiologist (n = 1, 5.3%), anesthesia residents (n = 2, 10.5%), nurse anesthetists (n = 2, 10.5%), nurses (n = 5, 26.3%), and a surgical technologist (n = 1, 5.3%) were interviewed. Twelve of the 14 themes within the Theoretical Domains Framework were discovered in transcripts. Barriers within these themes included lack of resources to pursue environmental sustainability in the OR and the necessity of maintaining sterility for patient safety. Facilitators included emphasizing surgeon leadership within the OR to reduce unused supplies and spreading awareness of the environmental and economic impact of surgical waste. CONCLUSIONS: Interviewed stakeholders were able to identify areas where improvements around surgical waste reduction and management could be made at the institution by describing barriers and facilitators to sustainability-driven interventions. Future surgical waste reduction initiatives at this institution will be guided by these important perspectives.
RESUMEN
INTRODUCTION: Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS: This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS: Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS: Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.
Asunto(s)
Apendicitis , Etnicidad , Humanos , Niño , Apendicectomía/efectos adversos , Alta del Paciente , Apendicitis/cirugía , Estudios Retrospectivos , Cuidados Posteriores , Grupos Minoritarios , Disparidades en Atención de SaludRESUMEN
PURPOSE: Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplication or gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment. METHODS: Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses. RESULTS: A total of 14,965 children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5 years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low. CONCLUSION: Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.
Asunto(s)
Reflujo Gastroesofágico , Enfermedades del Sistema Nervioso , Niño , Humanos , Recién Nacido , Lactante , Gastrostomía/métodos , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/cirugía , Reflujo Gastroesofágico/epidemiología , Fundoplicación/métodos , Nutrición Enteral , Enfermedades del Sistema Nervioso/complicaciones , Enfermedades del Sistema Nervioso/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION: Recurrent primary spontaneous pneumothorax (PSP) is often managed with a wedge resection (or blebectomy) and either pleurectomy or pleurodesis. There is a conflicting data regarding which approach is superior to reduce recurrence. Our objective is to evaluate the long-term recurrence rates following pleurectomy versus mechanical pleurodesis for recurrent PSP. METHODS: The PearlDiver Mariner Patient Claims Database was queried for patients aged 10-25 who were presented with PSP and underwent either pleurectomy or mechanical pleurodesis between 2010 and 2020. The primary outcome was recurrence and secondary outcomes included 30-day opioid prescriptions, pain diagnoses, and reimbursement. Kaplan-Meier analysis and Cox proportional hazards regression models were used with adjustment for age and sex. RESULTS: Of 18,955 patients presenting with PSP, 5.1% (n = 968) were managed operatively with either pleurectomy (18.3%, n = 177) or mechanical pleurodesis (81.7%, n = 791). There was no difference in the rate of recurrence between pleurectomy and mechanical pleurodesis (5-year risk of recurrence: 25.8% versus 26.5%, adjusted hazard ratio (HR) = 1.12 [95% confidence interval (CI): 0.79, 1.58]). Furthermore, there was no difference in rate of outpatient opioid prescription (49.2% versus 52.8%, P = 0.58) or pain diagnoses (22.0% versus 22.8%, P = 0.46) between pleurectomy and mechanical pleurodesis, respectively. The median reimbursement was higher following pleurectomy as compared to mechanical pleurodesis ($14,040 versus $5,811, P = 0.02). CONCLUSIONS: There is no significant difference in recurrence based on type of procedure performed for recurrent primary spontaneous pneumothorax. However, reimbursement is higher following pleurectomy. Given the similar outcomes but higher cost, we recommend mechanical pleurodesis over pleurectomy for recurrent PSP.
Asunto(s)
Pleurodesia , Neumotórax , Analgésicos Opioides , Humanos , Dolor , Pleurodesia/métodos , Neumotórax/etiología , Neumotórax/cirugía , Recurrencia , Cirugía Torácica Asistida por Video , Resultado del TratamientoRESUMEN
PURPOSE: Delayed enteral feeding (DEF) contributes to postoperative complications among children undergoing intestinal surgery. Various recent studies indicate the benefits of early enteral nutrition after intestinal surgery in adults. This systematic review and meta-analysis evaluates whether early enteral feeding (EEF) is beneficial in children who underwent intestinal anastomosis. METHODS: MEDLINE, PubMed, the Cochrane Library, and Web of Science databases were searched for RCTs that addressed the effect of EEF in children (younger than 18 years old) undergoing intestinal anastomosis. EEF was defined as starting enteral feeding before the 3rd postoperative day. Studies were selected based on predetermined inclusion and exclusion criteria. A meta-analysis was performed using RevMan 5.3 to estimate odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Four RCT studies met the inclusion criteria, comprising 97 cases with EEF and 89 cases with DEF. Enteral feeding started significantly earlier in the EEF group compared to the DEF group (MD = - 2.80; 95% CI - 3.11 to - 2.49; p < 0.00001). Postoperative anastomotic leak rate was unchanged between EEF and DEF groups (OR = 0.86; 95% CI 0.17-4.46; p = 0.86). The EEF group had a shorter length of hospital stay (MD = - 3.38; 95% CI - 4.29 to - 2.48; p < 0.00001), earlier time to bowel movement return (MD = - 0.57; 95% CI - 0.79 to - 0.35; p < 0.00001), lower incidence of surgical infection (OR = 0.27; 95% CI 0.08-0.90; p = 0.03), and faster tolerance of full enteral feeding (MD = - 2.00; 95% CI - 3.01 to - 2.79; p < 0.00001). Incidence of fever (OR = 0.37; 95% CI 0.10-1.31; p = 0.12), emesis, and abdominal distention (OR = 0.63; 95% CI 0.13-3.16; p = 0.58) were not different between the two groups. CONCLUSIONS: Early enteral feeding after intestinal anastomosis in children does not increase the risk of postoperative anastomotic leak, fever, emesis, and abdominal distention. However, early enteral feeding is beneficial as it promotes the return of bowel function, reduces the length of hospital stay and the incidence of surgical infection in comparison to delayed enteral feeding.
Asunto(s)
Anastomosis Quirúrgica , Nutrición Enteral , Adolescente , Adulto , Fuga Anastomótica , Niño , Procedimientos Quirúrgicos del Sistema Digestivo , Humanos , Intestinos/cirugía , Tiempo de Internación , Pediatría , Complicaciones Posoperatorias , Periodo Posoperatorio , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de TiempoRESUMEN
BACKGROUND: The long-term effects of postoperative complications following coronary artery bypass grafting (CABG) are unknown. METHODS: Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were queried for isolated CABG records from 2007 through 2012. Unadjusted and adjusted associations between individual postoperative complications and both mortality and all-cause rehospitalization were evaluated to 7â¯years using Cox proportional-hazards models and cumulative incidence functions. Because of nonproportional hazards, associations are presented as early (0 to 90â¯days) and late (90â¯days to 7â¯years). RESULTS: Of the 294,533 isolated CABG patients who had records linked to Medicare for long-term follow-up (median age, 73 years; 30% female), 120,721 (41%) experienced at least 1 of the complications of interest, including new-onset atrial fibrillation (30.0%), prolonged ventilation (12.3%), renal failure (4.5%), reoperation (3.5%), stroke (1.9%), and sternal wound infection (0.4%). Each of the 6 postoperative complications was associated with a significantly increased risk of mortality and rehospitalization to 7â¯years despite adjustment for baseline characteristics and the presence of multiple complications. Although the predominant effect of postoperative complications was observed in the first 90â¯days, the increased risk-adjusted hazard for death and rehospitalization continued through 7â¯years. CONCLUSIONS: Postoperative complications are associated with an increased risk of both early and late mortality and all-cause rehospitalization, particularly during the "value" window within 90â¯days of CABG. These findings underscore the need to develop avoidance strategies as well as cost-adjustment methods for each of these complications.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo/métodos , Anciano , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Readmisión del Paciente/tendencias , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Blood transfusion has been associated with poor outcomes in many disciplines, yet transfusion practices and related outcomes in esophagectomy are unknown. We analyzed the Society of Thoracic Surgeons General Thoracic Database to determine patient factors associated with transfusion after esophagectomy, risk-adjusted variation in transfusion practice among institutions, and the association of transfusion practice with mortality. METHODS: We performed a retrospective review of patients undergoing esophagectomy for cancer from October 2008 to December 31, 2014. Patient comorbidities and procedure variables were used to construct a risk model for transfusion. Using this model, each institution was assigned an observed to expected (O:E) transfusion rate. We examined institutional factors associated with variation in O:E transfusion rate. Finally, O:E transfusion rate was compared to risk-adjusted mortality to determine if there was an association of transfusion practice and survival. RESULTS: Seven thousand one hundred thirty-seven patients underwent esophagectomy at 182 institutions during the study period. The median unadjusted transfusion rate was 23.1%. The risk model for transfusion demonstrated patients who received transfusions were more likely to be older, female, and have low preoperative hemoglobin and other comorbidities, such as CAD, COPD, and low creatinine clearance. Patients who received a minimally invasive procedure were less likely to have received a transfusion.After adjusting for the characteristics above, 13 centers (7.1%) were classified as having lower than average O:E transfusion rate and 16 centers (8.7%) were classified as higher than average O:E transfusion rate.Institutions with lower than expected transfusion rates also had lower risk-adjusted perioperative mortality than institutions with higher than expected transfusion rates (median [IQR] = 0.90 [0.77-0.94] vs. 0.99 [0.94-1.06], P = 0.028). CONCLUSION: Age, female sex, CAD, COPD, renal insufficiency, and open technique are associated with transfusion after esophagectomy, while tumor stage and preoperative chemoradiation are not. There is wide variation in transfusion practice. Centers with lower than expected transfusion rate also had lower than expected perioperative mortality. At an institutional level, lower transfusion rates are associated with improved outcomes.
Asunto(s)
Transfusión Sanguínea/estadística & datos numéricos , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Hemorragia Posoperatoria/terapia , Sociedades Médicas , Cirujanos/estadística & datos numéricos , Cirugía Torácica , Anciano , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: There is limited data guiding treatment for positive margins following lobectomy for early-stage non-small cell lung cancer (NSCLC). Using data from the National Cancer Data Base, we sought to determine whether radiation therapy following lobectomy for stage I or II NSCLC was associated with improved overall survival in patients with positive margins. METHODS: Patients who underwent lobectomy without induction therapy for stage I or II NSCLC (1998-2006) with positive resection margins were selected. Patients were stratified by administration of radiation therapy following surgery, and overall survival was estimated using the Kaplan-Meier method. The association between radiation therapy and survival was adjusted for nonrandom treatment selection using Cox proportional hazards regression modeling. RESULTS: Positive margins were recorded in 1934 of 49,563 (3.9%) patients who underwent lobectomy for stage I or II NSCLC. Positive margin status was associated with significantly worse 5-year survival (34.5% versus 57.2%, P < 0.001). After selection of patients with positive margins and known radiation status and exclusion of patients who had upstaged disease or received radiation therapy for palliative indications, radiation therapy was used in 579 of 1579 patients (38.2%) but was not associated with a significant difference in the likelihood of death during subsequent follow-up (hazard ratio: 1.10, 95% confidence interval: 0.90, 1.35). CONCLUSIONS: Positive margins following lobectomy for stage I or II NSCLC are associated with reduced 5-year survival. Postsurgical radiation is not strongly associated with an improvement in overall survival among these patients.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Neoplasias Pulmonares/radioterapia , Neumonectomía , Anciano , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/patología , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Terapia Combinada , Femenino , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Modelos de Riesgos ProporcionalesRESUMEN
BACKGROUND: Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database. METHODS: The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS). RESULTS: For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest. CONCLUSION: Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach.
Asunto(s)
Neoplasias Renales/cirugía , Neuroblastoma/cirugía , Tumor de Wilms/cirugía , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Neoplasias Renales/mortalidad , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Neuroblastoma/mortalidad , Sistema de Registros , Estudios Retrospectivos , Tumor de Wilms/mortalidadRESUMEN
Alpha-1-antitrypsin deficiency (AATD) is grouped with chronic obstructive pulmonary disease (COPD); however, this may not be appropriate. This study assessed whether AATD confers a different prognosis than COPD following lung transplantation. We employed the United Network for Organ Sharing (UNOS) database, grouping patients by diagnoses of AATD or COPD. Kaplan-Meier methods and Cox modeling were performed to determine the association of diagnosis and overall survival. Of 9569 patients, 1394 (14.6%) had a diagnosis of AATD. Patients with AATD who received a single-lung transplant had reduced 1-year survival [adjusted hazard ratio (AHR): 1.68, 95% CI: 1.26, 2.23]. Among patients who received a bilateral lung transplant, there was no significant difference in survival by diagnosis (AHR for AATD as compared to COPD: 0.96, 95% CI: 0.82, 1.12). After the implementation of the lung allocation score (LAS), there was no significant difference in survival among patients who received a single (AHR: 1.15, 95% CI: 0.69, 1.95) or bilateral (AHR: 0.99, 95% CI: 0.73, 1.34) lung transplant by diagnosis. Lung transplantation is increasingly employed in the care of the patient with COPD. Although recipients undergoing LTX for AATD are at increased risk of both acute rejection and airway dehiscence post-transplant, in the post-LAS era, survival rates are similar for recipients with AATD in comparison with COPD.
Asunto(s)
Trasplante de Pulmón/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/genética , Deficiencia de alfa 1-Antitripsina/cirugía , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Pulmonar Obstructiva Crónica/cirugía , Análisis de Supervivencia , Estados Unidos/epidemiología , Deficiencia de alfa 1-Antitripsina/complicaciones , Deficiencia de alfa 1-Antitripsina/mortalidadRESUMEN
PURPOSE: Improvement in outcomes of LT for pediatric HB and HCC has been reported in small series. We analyzed national outcomes and changes in donor, recipient, and perioperative factors over time that may contribute to survival differences. METHODS: The UNOS database was queried for patients age <21 years that underwent LT for a primary diagnosis of HB or HCC (1987-2017). Subjects were divided into historic (transplant before 2010) and contemporary (transplant after 2010) cohorts. Baseline characteristics were compiled and examined. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: In total, 599 children with HB received LT (320 historic vs 279 contemporary). Concurrently, 141 children with HCC received LT (92 historic vs 49 contemporary). For both tumors, waitlist time decreased (HB 56.2 days historic vs 33.2 days contemporary, P = 0.017; HCC 189.3 days historic vs 71.7 days contemporary, P = 0.012). In the historic cohorts, patients with HB had a 1-year and 5-year OS of 84.6% and 75.1%, respectively. Survival for HCC was 84.4% and 59.9%, respectively. Outcomes improved in the contemporary era to 89.1% and 82.6% for HB, and 94.7% and 80.8% for HCC, respectively (both log-rank test P < 0.0001). CONCLUSION: Outcomes of LT have improved significantly, with contemporary survival now equivalent between these tumors and exceeding 80% 5-year OS. Future studies are needed to explore whether offering LT in patients that are resectable is justifiable.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatoblastoma/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado , Adolescente , Carcinoma Hepatocelular/mortalidad , Niño , Preescolar , Femenino , Hepatoblastoma/mortalidad , Humanos , Estimación de Kaplan-Meier , Neoplasias Hepáticas/mortalidad , Donadores Vivos , Masculino , Sistema de Registros , Estudios Retrospectivos , Donantes de Tejidos , Resultado del Tratamiento , Estados Unidos , Listas de EsperaRESUMEN
BACKGROUND: Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor in children, with current evidence limited to single-center studies. We examined treatment and clinical outcomes for pediatric and adult SPN with a national data set. METHODS: The 2004 to 2013 National Cancer Data Base was queried to identify all patients diagnosed with SPN. The cohort was stratified by age (pediatric and adult) defined as below 18 years and 18 years and above, respectively. Baseline characteristics and unadjusted outcomes were compared. RESULTS: We identified 21 pediatric and 348 adult patients with SPN. Both groups displayed similar demographic composition. Patients were commonly female (90.5% [pediatric] vs. 85.9% [adult], P=0.56) and white (66.7% vs. 68.3%, P=0.74). Tumor location was similar between adults and children. Median tumor size was similar between children and adults (5.9 vs. 4.9 cm, P=0.41). Treatment strategies did not vary between groups. Partial pancreatectomy was the most common resection strategy (71.4% vs. 53.1%, P=0.80). Both groups experienced low mortality (0.0% vs. 0.7% at 5 y, P=0.31). CONCLUSIONS: This study provides the largest comparison of pediatric and adult SPN to date. Children with SPN have similar disease severity at presentation, receive similar treatments, and demonstrate equivalent postoperative outcomes compared with their adult counterparts.
Asunto(s)
Bases de Datos Factuales , Neoplasias Pancreáticas/epidemiología , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Adolescente , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Marriage is linked to substantial societal and economic benefits, and it has been associated with improved outcomes following acute illness. However, it is not known if being married confers benefit to patients undergoing noncardiac surgical procedures. MATERIALS AND METHODS: Patients undergoing any noncardiac surgical procedure were included over a period of 19 months. All-cause mortality at 2 years was determined by linking patient records to the National Death Index. Risk adjustment was performed using Cox modeling and the Cleveland Clinic risk stratification index. RESULTS: Of the 11,588 patients included, 7830 (68.0%) were married at the time of surgery. There was a significant interaction between sex and marital status (P = 0.03), so the remainder of the analysis was performed separately by sex. Among men, not being married was associated with significantly worse survival (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.06, 1.63), whereas among women, there was no significant association between marital status and survival (HR: 0.94, 95% CI: 0.77, 1.15). Furthermore, divorced men (HR: 1.76, 95% CI: 1.25, 2.51) and never married men (HR: 1.53, 95% CI: 1.14, 2.05) had significantly worse survival than married men, whereas there was no significant difference between widowed men and married men, nor when comparing widowed, divorced, or never married women to married women. CONCLUSIONS: Among a diverse group of surgical patients, being married at the time of surgery is associated with significantly improved survival only among men. Focused efforts to improve social support for unmarried male patients may improve outcomes.